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UNITED STATES OF AMERICA. 



FUNCTIONAL DISORDERS 



OF THE 



NERVOUS SYSTEM IN WOMEN 



BY 

T. J. MCGILLICUDDY, A.M.,M.D. 

Consulting Physician to the Italian Hospital, X. Y; Surgeon-in-charge of the New York 

Mother's Home Maternity Hospital ; Surgeon-in-charge of the Metropolitan Dispensary 

and Hospital for Women and Children ; Fellow of the Neio York Academy of 

Medicine ; Member of the American Medical Association ; Member of 

the International Medical Congress, Berlin, 1691, etc, etc. 



ILLUSTRATED BY FORTY-FIVE WOOD ENGRAVINGS AND 
TWO CHROMO-LITHOGRAPHIC PLATES 



NEW YORK \-\%\l> r l 

WILLIAM WOOD AND COMPANY 

1896 



$ ^ 



-£-> 






Copyright by 

WILLIAM WOOD & COMPANY, 

1896. 



PREFx\CE 



The attention of the profession has been confined of late 
years too exclusively to surgical gynaecology and to dis- 
eases with marked pathological changes. Great strides 
have been made in the development of these branches of 
medical science. They have had many able exponents. 
Less has been written on medical gynaecology, although a 
subject equally deserving of research and one which will 
abundantly reward the scientific investigator. There are 
many important nervous disorders in women without de- 
terminable anatomical changes in either the brain or spinal 
cord. Although there is no interesting anatomico-patho- 
logical history to be detailed in such cases, they are so com- 
mon, and cause so much suffering, that we must give them 
the share of attention they deserve. 

They are not usually found in hospitals but are seen fre- 
quently in private practice, and very often in the upper 
strata of society. The observations which follow have no 
claim to completeness on the subject. It is only intended 
to draw the attention to a class of affections which is 
frequently seen, and not so minutely described as the im- 
portant organic diseases and surgical affections. 

In the consideration of the functional derangements of 
the nervous system in women, it should be remembered 
that many uterine and digestive disorders are simply 
a small part of a constitutional condition which requires 



IV PREFACE. 

treatment, leaving the uterine or other ailment to disap- 
pear of itself when the general health becomes restored. 
The diagnosis of functional disease should be carefully 
made, for even in chronic organic cases many important 
organic changes take place without the accompanying 
physical signs, and to determine the question whether an 
ailment is functional or organic will at times completely 
mystify the most competent and astute physician. It is 
hoped that this contribution will be of interest and some 
practical advantage to the general practitioner, from 
whose standpoint it is written, and of value to future ex- 
plorers in this interesting department of medical work. 

776 Madison Avenue, New York. 



CONTENTS. 



CHAPTER I. 

PAGE 

The Reflex Neuroses, 1 

CHAPTER II. 
The Cerebral Neuroses, or Psychoses, 27 

CHAPTER III. 
Spinal Reflex Neuroses, 34 

CHAPTER IV. 
Cardiac Reflex Neuroses, 42 

CHAPTER V. 
Vascular Neuroses, 47 

CHAPTER VI. 
Pharyngeal and Laryngeal Reflex Neuroses, . . .81 

CHAPTER VII. 
Bronchial Reflex Neuroses, 85 

CHAPTER VIII. 
Gastric Reflex Neuroses, 89 

CHAPTER IX. 
Intestinal Reflex Neuroses, 98 

CHAPTER X. 
The Renal Reflex Neuroses, 106 

CHAPTER XI. 

The Vesical Reflex Neuroses, 108 



VI CONTENTS. 

CHAPTER XII. 

PAGE 

The Reflex Genital or Hystero- Neuroses. . . .112 

CHAPTER XIII. 
The Glandular Reflex Neuroses, 118 

CHAPTER XIV. 
Ophthalmic Reflex Neuroses, 128 

CHAPTER XV. 
The Aural Reflex Neuroses, 137 

CHAPTER XVI. 
Lingual Reflex Neuroses, 140 

CHAPTER XVII. 
The Articular Reflex Neuroses, 144 

CHAPTER XVIII. 
The Dermal Reflex Neuroses or Dermatoses, . . . 149 

CHAPTER XIX. 
Hysteria, . .157 

CHAPTER XX. 
Hystero- Epilepsy, 183 

CHAPTER XXI. 
Hemicrania— Migraine, ....... 243 

CHAPTER XXII. 
Therapeutics, 251 



FUNCTIONAL DISORDERS 



OF THE 



NERVOUS SYSTEM IN WOMEN, 



CHAPTER I. 
THE REFLEX NEUROSES. 

Every woman suffers more or less, and many almost 
constantly, from functional derangements of some of the 
organic structures of the body. We are frequently con- 
sulted by those who, although suffering from no gross 
pathological condition, nevertheless require our aid for 
the great discomforts, both physical and mental, which 
these various functional disturbances entail, and we should 
make every effort to afford them consolation and relief. 

Many of these simple deviations from the normal are 
really precursors of conditions of a most serious nature. 
There is every reason to investigate carefully these minor 
ailments, because of their great frequency and the impor- 
tant bearing they have upon our success as practitioners. 

It is often claimed that many physicians are too scienti- 
fic and not sufficiently practical in their treatment of pa- 
tients. This is a matter we should guard against, because 
the physician's duty is first and foremost that of healing 
and not altogether that of solving scientific problems. No 
scientific physician is pleased when he finds he has lost 



» FUNCTIONAL NERVOUS DISORDERS. 

some of his patients because they have been discontented 
and annoyed at his lack of interest and sympathy for 
their minor functional disturbances, and that an arrant 
impostor has them in charge, because, by his tact and 
knowledge of human nature, he has readily relieved their 
imaginary or trifling ailments. Old ladies and lay 
persons generally are often loud in their praises of these 
irregular practitioners simply because they have given at- 
tention to these minor difficulties. 

Among the more important of these lesser derange- 
ments are the reflex neuroses, which will be considered 
from the standpoint of the general practitioner or gynae- 
cologist. There are many who seem to consider them 
insignificant, and some even appear to doubt their actual 
existence. 

The reflex neuroses are, of course, symptoms, but yet are 
more than simple symptoms as they are frequently pro- 
ductive of more distress than the organic disease from 
which they take their origin. 

Neurosis is a generic term for conditions of hyperes- 
thesia or disturbance of the nervous system which simu- 
late disease in an organ that is healthy, or without evident 
lesion of any of its parts. They may be general or local. 
Every general practitioner should be well acquainted with 
them, and every specialist also. The latter must first have 
the knowledge of the general practitioner, otherwise many 
mistakes will certainly be made in the diagnosis and treat- 
ment of chronic ailments. For example, if the confiding 
and unsuspecting patient with a run-down constitution — 
the result of anxiety, bad air, and a worse diet — with a 
headache and some abdominal or uterine symptoms, strays 
into the office of an enthusiast in ocular tenotomy, he will 
probably want to relieve her distress by dividing the rec- 



THE REFLEX XEUROSES. 3 

tus muscle for eye-strain. If, however, as is more likely, 
she applies to a surgical gynaecologist of a certain class, a 
symptomatic uterine catarrh, an inoffending laceration, or 
a harmless, retiring cystic ovary will be pounced upon by 
this enlightened specialist, and receive most vigorous treat- 
ment; and if he does not always sterilize carefully his in- 
struments he usually succeeds in sterilizing the patient. 
Or perhaps her destiny may lead her into the office of a 
digestive specialist, who, of course, diagnoses stomach trou- 
ble as the cause of all her ills, and proceeds to lower sev- 
eral feet of rubber hose into her surprised stomach, and 
treat that organ to a wholesome bath. If our specialism 
be allowed to run into exclusivism, very shortly the only 
safe man for a patient to consult will be the old-fashioned 
general practitioner with all his faults and deficiencies. 
The benefits of specialism are many and most important, 
but there are also some dangers to be avoided. 

The neuroses of women should be studied carefully from 
both an anatomical and physiological standpoint. There 
is indeed much yet to be learned and plainly stated; The 
nervous system must be studied by the general practi- 
tioner as well as by the specialist, otherwise he is shut out 
from a true knowledge of disease. The important bear- 
ing of nutrition upon all ailments must be carefully con- 
sidered before a practical common -sense solution of the 
many difficult problems which present themselves can be 
reached. 

That many nervous disorders are caused reflexly, there 
can be no doubt. There is much difference of opinion in 
regard to the causation of the various neuroses, but many 
cases are recorded illustrating the fact that peripheral 
irritation is a very decided factor in their production. 
Irritation may be set up in any part of the body, and may 



4 FUNCTIONAL NERVOUS DISORDERS. 

result in a reflex disorder in a distant organ. Some of 
the sources of irritation which may be noted, are : 

In the Digestive Organs — Indigestion. 

a. Stomach — Gastric catarrh, ulcer. 

b. Intestines — Para sites, ulcers, intestinal catarrh. 

f Haemorrhoids. 

c. Rectum-^ ™ cers ; 

| Ihread worms. 

(_ Pruritus ani. 

In the Genitourinary Organs— Inflammations. 
Internal- — 

a. Kidneys — Calculus. 

I Catarrhal states. 

^ . ( Inflammations. 

c. Ovaries — i M ,.-, ,, 

( Morbid growths. 

d Uterus— i Tnflammation s- 
( Morbid growths. 
External — 

a. Vulva — Pruritus, herpes. 

b. Clitoris — Adhesions. 

( Inflammation. 
In the Respiratory Organs — -j Irritation (catarrhal) . 

( New growths. 

In the Eyes— -i Eye strain - 

( Errors of refraction and accommodation. 

IN the JiARS j Impacted cerumen. 

The foregoing is by no means a complete summary of 
the causative factors which operate in the production of 
reflex disturbances, yet they are fair examples of what we 
should look for when searching for some peripheral irrita- 
tion to assist us in the diagnosis and treatment of disease. 

Although severe local disease may exist in an organ 
with but little reflex disturbance, still, usually many re- 
flex nervous disorders depend on slight peripheral irrita- 



THE REFLEX NEUROSES. 

tions ; and these reflex irritations, if they are not the abso- 
lute and complete causes of the nervous phenomena, are 
certainly exciting causes in those individuals who have 
a predisposing temperament. 

No one has more thoroughly investigated the reflex 
hystero-neuroses than Dr. George J. Engelmann, of St. 
Louis, whose contributions on this subject are extremely 
valuable. Both the sympathetic and the spinal systems 
are involved, and a condition of anaemia or lowered vital- 
ity is the most important causative agent in producing the 
hypersensitiveness of the nervous system. This weak- 
ness is the most prominent factor in the disorder. The 
study of the subject is of the greatest importance in the 
diagnosis of disease — for instance, asthma, which one may 
be led to consider a local pulmonary or cardiac disease, is 
often of reflex origin, either from the uterus, gastrointes- 
tinal tract, or from localized growths in the posterior 
nares. The spasmodic croup and convulsions in children 
are good examples of reflex nervous action. 

Reflex or nervous diarrhoea is often seen in horses and 
other animals. It is also very common as an intestinal 
neurosis in the human subject, and is a result of distur- 
bances of the sympathetic system through mental influ- 
ences. The condition is analogous to that where the 
sound of running water causes a reflex stimulation of the 
renal glands, thus assisting urination. 

Strong mental impressions stimulate both the vesical 
and rectal nerves of the young soldier when going into 
battle for the first time, while the uterine nerves in the 
young female emigrant produce amenorrhoea from the ex- 
citement incident to leaving home and coming to a for- 
eign country. The diarrhoea of scared soldiers and of 
nervous horses is of similar origin, and the emission of 



6 FUNCTIONAL NERVOUS DISORDERS. 

the malodorous fluid of the Mephiticus americanus when 
pursued or frightened may be explained in the same way. 

The differential diagnosis between a severe reflex head- 
ache depending upon uterine or digestive disease, such as 
pelvic cellulitis or indigestion with constipation, and be- 
ginning exophthalmic goitre, where a rapid pulse and 
swollen thyroid are among the earliest manifestations, is 
often exceedingly difficult, as the mere fact of entering 
a physician's office for examination will often produce in 
nervous young women a great amount of excitability. 
This may give rise not only to a rapid pulse, but also 
produce a globus hystericus — itself possibly a temporary 
congestion of the thyroid. Many of these reflex condi- 
tions are certainly common and are yet not always appre- 
ciated at their true value. They should be carefully stud- 
ied in order that the differentiation between functional and 
organic or structural disease in an organ may be readily 
determined. They are of interest not only to the gynae- 
cologist, on account of their frequency in women, but to the 
aurist, the oculist, the dermatologist, the neurologist, and 
the surgeon. In this class of cases, although the uterus is 
a great factor in their production, the stomach and intes- 
tines play fully as important, if not a greater part. They 
may be divided according to the following classification. 

The neuroses of the nervous system. 

The neuroses of the circulatory system. 

The neuroses of the digestive system. 

The neuroses of the respiratory system. 

The neuroses of the genito-urinary system. 

The neuroses of the glandular system. 

The neuroses of the cutaneous system. 

The spinal and cerebral centres are not only implicated 
in these disorders, but the ganglionic and vasomotor 



THE REFLEX XEUROSES. 7 

nerves probably even more so. This is readily seen in the 
flushes, perspirations, or blanching of the surface of the 
body. The cardiac and solar plexuses are without doubt 
of great importance in these ganglionic disturbances. 
The reflex neuroses are not to be confounded with symp- 
toms from local mechanical pressure — mere local inflam- 
matory neuralgia. They may, however, cause severe 
pain. Every one is familiar with the common reflex neu- 
roses — e.g., those of pregnancy — but it is with the less 
common, but no less interesting varieties that we are 
concerned at present. They are important on account of 
their misleading qualities, and are of great practical im- 
port in the daily routine of medical practice. 

These are the symptoms which connect general with 
special medicine, and without a knowledge of them the 
practitioner no longer remains a scientific physician, 
but gradually drifting into exclusivism, becomes little 
more than a skilled mechanic, and under his care the 
wrong organ will often receive the benefit of the medica- 
tion. 

Comparatively little has been written upon this subject. 
Fordyce Barker was well aware of its importance, and 
wrote a work dealing with some of the hystero-psychoses, 
entitled " Uterine Disease, an Exciting Cause of Insan- 
ity." Hodge and Tilt have recorded many cases. Hegar 
has studied them, and has shown also their importance in 
gynaecology. The alienist Esquirol has pointed out their 
connection with insanity. Dr. Engelmann has given them 
special study in an elaborate article in the Gynaecological 
Transactions for 1887, and Dr. H. J. Boldt has described 
the " Cardiac Neuroses in Connection with Ovarian and 
Uterine Disease" in an interesting article in the American 
Journal of Obstetrics for August, 1886. A number of 



8 FUNCTIONAL NERVOUS DISORDERS. 

other writers have also enlarged upon this interesting 
subject. 

The frequency of hystero-neuroses may be judged when 
Dr. Engelmann states that he has observed in private 
practice, in the ten years since writing his first paper in 
1877, over a thousand cases of menstrual hystero neuroses 
of the stomach alone. 

The intimate connection, reflexly, between the uterine 
and digestive organs is often manifested by gastralgia in 
cases of retroversion, the cure of the retroversion causing 
the immediate and permanent disappearance of the pain 
in most cases. Cases of violent vomiting occurring during 
the act of coition have been noted. Here, in this true re- 
flex neurosis there is generally an excessive secretion of 
hydrochloric acid. A case of this kind has been recently 
reported in the Medical Record by Dr. M. Gross. The 
digestive disorders are frequent causes reflexly of genital 
weakness, although anaemia may also be present. 

No part of the body should be regarded as an indepen- 
dent tissue, as each one holds the closest relations with the 
rest of the system and is always influenced by morbid 
conditions in the other parts. 

Digestive and uterine disorders at the menopause fre- 
quently manifest themselves by reflex disturbances of 
sensation in the lower extremities. One of the curious 
symptoms of such disturbance is diminished sensibility 
and a feeling as if the patient were walking over feather 
beds, or large puff balls, and sinking at every step. Cramps 
of the muscles of the calf of the leg are also of common 
occurrence in these disorders. These cramps are, in my 
opinion, of vasomotor origin, and when attacking the toes 
or calves, are similar in many respects to migraine. It is 
not alone a muscular cramp, the circulation being prin- 



THE REFLEX NEUROSIS. 9 

cipally disturbed. There is much between the two that 
is analogous. 

Almost every gynaecological surgeon, who has given the 
matter any attention, has seen reflex neuroses dependent 
upon lacerated cervix. The scar tissue probably includes 
nerve filaments, and so keeps up a persistent irritation. It 
is not the specialist but the general practitioner who is 
most liable to discover the various reflex neuroses and 
give them their proper weight and treatment. 

No attempt whatever has been made to go into the sub- 
ject exhaustively. It is simply desired to speak of symp- 
toms and conditions which are commonly met with, espe- 
cially in women patients, and to consider some of the 
disorders which lie in that comparatively unknown region 
between gynaecological surgery and general medicine. 

It is to be regretted that many gynaecologists, in the treat- 
ment of diseases of women, never permit their range of vis- 
ion to extend beyond the pelvis. This is more particularly 
so in the case of the younger physicians who become spe- 
cialists immediate!}" upon graduating, and who have never 
bad the advantages to be derived from a general practice. 

Neuroses of ophthalmic nature require careful investi- 
gation of the digestive function, the kidneys, and the 
uterus. A regulation of the diet, or some gynaecological 
treatment, is often all that is required. Many cases of 
apparent gastric disease have been treated for years by 
medication directed to the stomach, when an endometritis 
was the principal causative factor in the production of the 
symptoms. And vice versa many a leucorrhcea has been 
treated locally by douches and astringents when chronic 
dyspepsia and hepatic congestion were responsible for its 
continuance. Through the ramifications of the spinal 
and ganglionic nerves irritation in one part of the body 



10 FUNCTIONAL NERVOUS DISORDERS. 

shows itself in distant organs. Thus, cerebral irritations 
may expend their force in gastric distress, and again, 
most of the headaches from which patients suffer are the 
result of disturbances within the abdominal and pelvic cav- 
ities. By a series of plates illustrating this subject it is 
hoped to exhibit in a graphic manner certain pathological 
facts, and still further to establish certain connections and 
functions of the ganglionic system in order that some ob- 
scurities in the physiology of the nervous system may pos- 
sibly be removed. 

A thorough knowledge of these reflex symptoms is ex- 
tremely important, as it helps to broaden the domain of 
medical treatment, and careful study of the subject will 
increase the usefulness of both specialist and general prac- 
titioner, and tend to promote more harmonious relations 
between the different branches of medical science. The 
methods of treatment of the old-fashioned general practi- 
tioner are much more to be commended in the treatment 
of uterine disease than are those of some of the up-to-date 
gynaecologists, who think it their bounden duty to make a 
digital and visual examination of every patient, married 
or single, who enters their offices, regardless of the fact 
that the uterine symptoms are simply the results of over- 
work, bad hygiene, and poor diet, the rectification of which 
would cause them speedily to disappear, or of local con- 
ditions alone. It is really criminal to make a physical 
uterine examination of a young unmarried woman unless 
such a course is unmistakably indicated. The great ma- 
jority of these cases do not call for any such procedure. 
In the married it is entirely different, and examinations 
may be made much more freely. 

I have seen violent attacks of apnoea produced by uter- 
ine disease, and many of the cerebral neuroses are the re- 



THE KEFLEX LEUKOSES. 11 

suits of irritations springing up in the gastro-intestinal 
tract. Much of the irritability, bad temper, and moral 
perversion takes its origin in the abdominal cavity. The 
differential diagnosis between a reflex neurosis and a local 
inflammatory condition is often difficult, and many times 
the two are combined. When the neurosis is present the 
symptoms are out of proportion to the local pathological 
changes. We find lesions and pathological conditions 
existing in various parts of the body which, increasing in 
severity, increase correspondingly the severity of the neu- 
rosis, and treatment directed to these pathological states 
decreases the neurosis or causes its disappearance, while 
local remedies applied directly to the seat of the neurosis 
are productive of no benefit. 

Some of the neuroses are very persistent. Cases of 
hemiansesthesia, hemiplegia, and paraplegia lasting for 
years have frequently been seen. 

I am led to believe that in the reflex neuroses there is 
undoubtedly local congestion dependent on the irritation. 
In the globus hystericus in many instances this con- 
gestion can be determined by placing the finger, during 
its existence, on the front of the throat just below the lar- 
ynx, where it will be found very tender to the slightest 
pressure. 

The digestive and genital organs of women are so inti- 
mately connected by their nervous and vascular relations 
that to treat them separately, and yet successfully, is im- 
possible, therefore it is readily seen how important it is 
for every gynaecologist to be thoroughly familiar with the 
digestive disorders. As I have already said in an article, 
the uterus, tubes, and ovaries are often treated as if they 
were in no way connected with each other ; so it is with 
the digestive tract. Its connection with the genital 



12 FUNCTIONAL NERVOUS DISORDERS. 

organs is so extremely intimate that neither of them 
should be treated without a careful investigation of the 
other, lying as they do in the same cavity, with the same 
vascular and nerve supply. 

The skin, digestive and nervous systems are very inti- 
mately connected. Dermatoses, where the eruption covers 
the nose and upper part of the cheeks in butterfly form, are 
very common in the country districts where large quanti- 
ties of indigestible fried foods are eaten. The dermatoses 
of reflex origin are very numerous. The laryngologist 
and rhinologist also should give special attention to these 
disorders. 

Dr. S. C, a personal friend, tells me that every month 
or two, when suffering from an attack of aggravated indi- 
gestion, he also has regularly a severe pharyngeal and ton- 
sillar inflammation accompanying it. This, however, 
might be due to an extension of the disease by continuity 
along the oesophagus. Yet it is probably of reflex origin. 
Dr. L., after a continued indulgence in strong coffee, is 
always attacked with severe congestion of the nasal 
mucous membrane, and coryza, which in this case is 
nothing more than a reflex neurosis. These reflex symp- 
toms have been to a great extent ignored by the profession 
as a whole. The ancient Eomans recognized the conges- 
tion and enlargement of the thyroid as a result of uterine 
irritation. 

Probably the most common of all the neuroses is the 
well-known morning sickness of pregnancy; migraine, 
and other types of headache dependent on gastric and 
liver disturbances are also good examples of the reflex 
neuroses. 

It is not supposed that grave diseases, such as epilepsy, 
chronic mania, and other organic diseases of the nervous 



THE REFLEX NEUROSES. 13 

system, are dependent upon slight peripheral irritations, 
but it is certain that many important and decided func- 
tional disorders are. On the other hand, it may be said 
that there is not the slightest doubt that there have been 
many errors in ascribing conditions depending upon a 
general blood state, the result of mal-assimilation or auto- 
infection, to some slight peripheral disturbance. Some 
physicians are inclined to repudiate entirely the reflex 
theory of functional disorders, and this seems to have been 
quite fashionable of late. The study of the reflex neu- 
roses is nothing more than a study of the sj'mptoms of 
disease which manifest themselves in distant portions of 
the body. 

A perfect classification of the reflex neuroses of individ- 
ual organs is at present impossible, but for clinical pur- 
poses we may include the following among the more com- 
mon forms : 

1. Cerebral. 10. Kenal. 

2. Spinal. 11. Vesical. 

3. Cardiac. 12. Genital. 

4. Vascular. 13. Glandular. 

5. Pharyngeal. 14. Ophthalmic. 

6. Laryngeal. 15. Aural. 

7. Bronchial. 16. Lingual. 

8. Gastric. 17. Articular. 

9. Intestinal. 18. Dermal. 

Many of these are combined, as in the cerebro-spinal and 
gastro-intestinal. And two or more may exist at the 
same time, as gastric and dermal, cardiac and respiratory, 
vascular and glandular. 

In his article "A Clinical Study of Neuralgias," in the 
New York Medical Journal, July 30th, 1887, Dr. Dana 



14 FUNCTIONAL NERVOUS DISORDERS. 

says in speaking of The Origin of " Reflex" or Transferred 
Neuralgias and Pain: 

" No point connected with the clinical history of neural- 
gias is of more interest than that of their so-called ' reflex ' 
origin. The production of migraine has been attributed, 
as we have seen, to the stomach and liver, to the eye, the 
tonsils, and the nose. Digital, plantar, cardiac, intercos- 
tal, and, in fact, all the neuralgias have been attributed to 
extrinsic causes. So much has appeared in literature re- 
garding the effects of such remote irritation that the im- 
portance of this influence has perhaps become exaggerated. 
At the same time the subject is one deserving of further 
and persistent study until its present many obscurities are 
removed. 

" In this study it is to be remembered that the term re- 
flex used here is not technically a correct one. An irrita- 
tion in the stomach may cause a pain which is felt in the 
forehead. The impulse, starting in the stomach nerves, 
is conveyed to the cortex of the brain, and this is felt as a 
sensation excited by the trigeminal nerve. It is a trans- 
ferred sensation, not a reflex one. since the impulse is 
afferent only, and the outward reference of the pain is 
purely psj^chical. 

"Reflex pains are, therefore, really 'transferred pains,' 
as a rule. In some cases it may be, however, that irrita- 
tions provoke reflex vasomotor changes in remote parts, 
and the ansemia or congestion thus produced causes pain. 
There may be, therefore, 'indirectly produced reflex 
pains.' The term reflex pain is so widely used that I can- 
not attempt to discard it. I use it, however, with the ex- 
planation here given. . . . 

"Irritations from the stomach cause reflexly a larger 
variety of pains. It is not possible to decide always 



THE REFLEX NEUROSES. 15 

whether these pains are reflex, or are due to vaso-motor 
disturbances or the circulation of morbid products in the 
blood as in cases of fermentative dyspepsia, and of consti- 
pation associated with dyspepsia. 

" We all know that the simple ingestion of a glass of ice- 
water will cause a sharp frontal or temporal pain. Lau- 
der Brunton finds that constipation and presumable intes- 
tinal irritation cause a diffuse frontal headache over the 
whole brow. When there is no constipation and the con- 
dition is one of gastric irritation the pain is either just 
above the eyes, or more rarely in the occiput (when it will 
be relieved by acids) , or just at the roots of the hair (when 
it will be relieved by alkalies). . . . 

" The scapular or shoulder pains in dyspepsia, and the 
pains felt between the scapulae, due to the involvement of 
the posterior branches of the second to the sixth intercos- 
tal nerves, are common phenomena familiar to all. 

" Gastric irritations must have a certain severity to be 
felt as pain in the stomach or epigastrium, and in these 
cases there is doubtless, as a rule, some muscular spasm 
of the stomach walls. 

"The milder irritations produced by gas, undigested 
food, excess of acid, etc., seem to be reflected most often 
upon the upper intercostal nerves or the cardiac nerves, 
vagal or sympathetic. The headaches in gastric irrita- 
tion so often involve some toxic element that we cannot 
speak of their origin with much positiveness. 

" The stomach and intestines are probably the most fre- 
quent cause of transferred pains; after this I would place 
the uterus and its appendages, and next the eye or heart. 
Lange considers that the heart ranks second. 

" In kidney disease neuralgic pains may be felt in the 
lumbar region, radiating forward to the lower abdomen 



16 FUNCTIONAL NERVOUS DISORDERS, 

and genitals— in other words, a lumbo-abdominal neural- 
gia is produced. In a case of renal colic I have observed 
the pain to be repeatedly centred about the anterior supe- 
rior crest of the ilium. 

"Pains started up by the gall-bladder are felt in the 
right side of the thorax and right arm, while it is one of 
the aphorisms of medicine that disorders of the liver may 
cause pain in the right shoulder. Bilious headaches 
cured by a dose of calomel I have observed to be located 
sometimes in the vertex and occiput. 

" In abscess of the spleen there is a pain felt in the left 
shoulder (Grotonelli, Wardell). 

" Lange says (loc. cit.) that in uterine troubles the re- 
flex pains occur oftenest in the form of arthralgias. I 
have had a patient suffering with painful spasms of the 
bladder who had intense pain in the palms of the hands 
every time she had a bladder spasm {Medical Record, 
July 25th, 1885) ; another patient, while pregnant, suf- 
fered from digital neuralgia, and in a third case reported 
by myself, a patient of Dr. Nilsen's, suffering from ova- 
rian prolapse, had severe and continuous neuralgic pains 
in the wrist. Studies of the cause of reflex pains in the 
feet show that they may be referred in almost all cases to 
irritation of the genito-urinary tract, and occur more often 
in the male {Medical Record, July 25th, 1885). The 
pains of uterine disorder, when reflected down, appear 
rarely to go below the knee; in other words, they affect 
the lower branches of the lumbar plexus, and not the 
sacral nerves. 

" It has been stated that pain in the heels may be caused 
by ovarian abscess. In my experience, such pains are 
due to lithsemic and neurasthenic conditions, and will be 
relieved by remedies addressed to such states. It may be 



THE REFLEX NEUROSES. 17 

said in general, then, that pelvic irritations are felt most 
frequently in the upper and short branches of the lumbar 
plexus, next perhaps in the intercostal nerves and upper 
cervical nerves, then in the trigeminus, and last in the 
hands and feet. 

" Lesions in the lung itself cause reflex pains in the 
form of intercostal neuralgia. Slight pulmonary conges- 
tions, such as occur at the very onset of phthisis, may 
cause intercostal neuralgia, and Anstie speaks of the value 
of these pains as warnings of the approach of phthisical 
disease. Apart from these neuralgias, the lung is very 
rarely an excitant of reflex pains, perhaps because its 
nerve supply is small, aside from the sensory fibres of the 
vagus. Further study, however, may show that lung 
irritation may cause some of the painful affections of the 
larynx, tongue, or throat. 

" The question now arises whether, with these various 
facts before us, any general statements can be made with 
regard to the production of transferred pains. If we 
study them in connection with the anatomical arrange- 
ments of the cerebro-spinal and so-called sympathetic sys- 
tem, it is possible that the diffusion and transference of 
pain, though in 'a mighty maze,' will not appear entirely 
without a plan. 

" The cerebro-spinal nerves are sent out from their cen- 
tres in divisions or companies of seven, and each company 
acts together and serves a common definite physiological 
purpose. These divisions are : 

"1. The oculo-motor nerves, the trifacial, and the sev- 
enth — which supply motion and feeling to the face and 
anterior scalp. The remaining cranial nerves supply in- 
ternal parts. 

" 2. The four upper cervical nerves forming the cervical 



18 FUNCTIONAL NERVOUS DISORDERS. 

plexus. This leash of nerves supplies motion and sensa- 
tion to the neck and occiput, and controls the movements 
of the cephalic extremity. It is in close connection with 
the trifacial, both at its origin and periphery, both di- 
rectly and via the sympathetic. It is subjected to much 
the same disturbances, and may be looked upon as physio- 
logically almost a part of the first set — i.e., of the com- 
mon sensori-motor cranial nerves. 

" 3. The third leash of nerves is composed of the last 
four cervical and first dorsal. They form the brachial 
plexus, and furnish motion and sensation to the upper ex- 
tremities. 

"4. The fourth set includes the dorsal nerves from the 
second to the sixth. This supplies the chest wall, includ- 
ing the pleura, and with the sympathetic the lungs 
beneath . 

" 5. The fifth set consists of the lower seventh to elev- 
enth intercostals, which supply motion and sensation to 
the abdominal walls, to the lower dorsal muscles, and the 
skin over them. 

" 6. The sixth set consists of the first four lumbar 
nerves with part of the twelfth dorsal, which is really a 
lumbar nerve. This supplies motion and sensation to, in 
general words, the hip girdle — i.e., the muscles (erector 
spinae, etc.) of the loins, those of the anterior, inner, and 
outer portion of the thigh, and the skin over these regions, 
extending down to the upper half of the buttock and to 
the groin, scrotum, and labia. It is the lumbar plexus 
which furnishes most of this supply. 

"7. The seventh and last set consists of the sacral 
nerves, whose anterior branches (those of the first four, 
with the lumbo-sacral cord) form the sacral plexus. This 
supplies the external genitals of the male, the clitoris and 



THE EEFLEX NEUROSES. 



19 




Area I. 
Area II. 
Area III. 



Area IV. 
Area V. 



Strands of 

cerebrospinal 

nerves. 



Trigeminus, 
facial, etc. 

Upper 4 cervi- 
cal. 

Lower 4 cervi- 
cal and 1st 
dorsal. 

Upper 6 dorsal. 

Lower 6 dorsal 
except last. 



Area VI.; 12th dorsal, 4 
i lumbar. 



Area VII. 5th lumbar and 
5 sacral. 



Distribution. 



Face and its orifices, 
anterior scalp. 

Occipital region, 
neck. 

Upper extremities. 



Thoracic wall 

Abdominal wall, up- 
per lumbar, upper 
lateral thigh sur- 
face. 

Lumbar region, up- 
per gluteal, ante- 
rior and inner thigh 
and knee. 

Lower gluteal, pos- 
terior thigh, leg. 



Associated 

ganglia of 

sympathetic. 



4 cerebral. 

1st cervical. 

2d and 3d cervi- 
cal, 1st dorsal. 

1st to 6th dorsal. 
5th to 12th dor- 
sal. 



1st to 4th lum- 
bar. 



1st to 5th sacral 



Main distribution. 



Head. 

Head (slightly to 

heart) . 
Heart. 



Lungs. 

Abdominal viscera, 
testes, ovary, 
fundus uteri via 
renal plexus. 

Pelvic organs. 



To pelvic organs, 
the sympathetic 
supply being 
small. 



Figs. 1 and 2.— Diagram showing the distribution of the seven cerebro-spinal 
strands of nerves, and the location of transferred pains and neuralgia. (After 
Dana.) 



20 FUNCTIONAL NERVOUS DISORDERS. 

part of the vagina, the perineum and external sphincter 
and the lower buttocks, and the posterior part of the thigh 
and leg, except its inner side. In a general way we may 
state that the lower portion gives motion and sensation to 
the legs and posterior thigh (the sciatic) ; the upper portion 
to the genitals and the gluteal, perineal, and anal region 
(superior gluteal, small sciatic, pudic). 1 

u Now each of these seven sets of nerves is in intimate 
connection by two branches with the sympathetic ganglia, 
and through these with the viscera of the different cavities. 
The accompanying diagram shows better than any descrip- 
tion what this relation is. 

" I. The first two leashes of nerves are connected most 
intimately with the four cerebral sympathetic ganglia 
(ophthalmic, otic, submaxillary, spheno-palatine) and with 
the upper cervical ganglion. 

" We can understand how irritations in the cranial cav- 
ity may be reflected almost indifferently upon the trigemi- 
nal or upper cervical nerves. 

" II. The third leash of nerves to the upper extremity is 
connected with the three cervical and first intercostal gan- 
glia, all of which go to make up the cardiac nerves. 

" Hence irritations of the heart are reflected so often in 
the shoulder and. down the arm. 

" III. The first six nerves of the thoracic wall are con- 
nected with the corresponding sympathetic ganglia which 
supply the lung tissue, and this anatomical fact may ex- 
plain why in slight pulmonary congestions pain may be re- 
ferred to the intercostal nerves. 



1 The sides of the body and both upper and lower extremities, ex- 
cept a portion of the legs, are supplied by lateral branches of the 
spinal nerves; the back, from occiput to iliac crest, by dorsal 
branches. 



THE REFLEX NEUROSES. 21 

" IV. The fifth leash of nerves, fifth to the eleventh in- 
tercostal, is connected with the sympathetic ganglia, which 
supply nerves to the abdominal viscera via the splanchnic 
nerves. The great splanchnic supplies all the abdominal 




Fig. 3.— Chart Showing the Different Levels of the Cerebro-spinal and Sympathetic 
Nerve-supply. Cerebro-spinal nerves represented on the right side ; sympathetic 
nerves on the left side. (After Dana.) 

viscera, including the visceral serous membranes, except 
the kidneys. These are more largely supplied by the small 
splanchnic which arises from the eleventh and twelfth 
thoracic ganglia. The renal plexus in turn sends branches 



22 FUNCTIONAL NERVOUS DISORDERS. 

to the spermatic cord, testes, ovary, and fundus uteri, so 
that those parts of the pelvic organs are especially con- 
nected with the lower dorsal nerves ; hence irritations of 
ovary, testes, cord, part of the uterus and kidneys, are 
often reflected as pains in the region of the kidneys and in 
the groins. It is, perhaps, over this arc that the low-down 
one-sided pains so often felt over the ninth to twelfth ribs 
originate. 

"V. The lumbar strand of nerves is connected with the 
lumbar ganglia and via the aortic plexus with the descend- 
ing colon, sigmoid flexure, and upper part of the rectum ; 
through the hypogastric plexus with the pelvic organs 
which it joins the sacral nerves and ganglia in supplying. 

"VI. The genital organs (vagina, cervix uteri, penis, 
prostate), except the testes and ovaries, are in close con- 
nection with the sacral strand of nerves (the seventh) ; the 
other pelvic viscera are more abundantly supplied by the 
lumbar and lower dorsal strands. Hence we find sciaticas 
and podalgia, and reflex pains throughout the lower ex- 
tremity in urethral irritations, rarely in irritations of the 
testes, ovary, or higher parts of the pelvis. These latter 
cause more often lumbo-abdominal neuralgias. 

" In attempting to explain the reflex pains from the vis- 
cera, I am led to the belief that the pneumogastric nerve 
must be left out of account as a direct factor. The mass 
of the sympathetic nerves to the sensitive thoracic, ab- 
dominal, and pelvic viscera, are made up of white, medul- 
lated nerves that come directly from the cord. These 
nerves carry sensory fibres, and their excitation is painful 
(Ludwig, O. Nasse). 

" Whether it be the heart, stomach, or uterus, therefore, 
irritations that excite pain more probably pass up to the 
brain via the spinal nerves, their posterior roots, and the 



THE REFLEX XEUR0SES. 23 

spinal cord. Having, however, to travel through two or 
three sets of ganglia, it is easy to understand how they 
may become diffused, and travel up paths belonging to 
another strand of nerves, and so be referred by the mind 
to a place remote from their origin. " 

I have taken the liberty of quoting very extensively from 
Dr. Dana's article on account of its great value in the 
elucidation of the subject. 

Sometimes transferred pains are of organic origin and 
due to the effects of pressure. This is illustrated in the 
following case reported by Dr. John Hilton : 

" Within the last three months I was requested to see a 
young lady from the country on account of some painful 
symptoms she had in her right hand, especially in the little 
finger and the ring finger. Associated with these symp- 
toms there was the suspicion of an aneurism of the right 
subclavian artery. I will not trouble you with all the 
particulars of this case, but only those which bear upon 
the suggestions before us. The patient had a slight, hard 
swelling upon the first rib, which her mother thought had 
resulted from a fracture that occurred in her childhood, 
she being now about nineteen years of age. The swelling 
had lifted up the subclavian artery very much, and gave 
it the appearance of unusual pulsation, and upon close ex- 
amination a sort of aneurismal bruit could be heard, ap- 
parently the result of some enlargement encroaching upon 
the subclavian artery. There was really no aneurism. 
This was a case in point, where something had occurred 
to the first rib, possibly a fracture (of that I have my 
doubts, still it might have been so), which led to the pres- 
sure upon this ulnar nerve, and had caused the loss of sen- 
sation in the little and the adjoining finger, the loss of tem- 
perature in those two fingers especially, and very constant 
pain in them. These are, as far as I can see, conditions of 
a case, which might ultimately terminate in gangrene of 
the fingers. In the case of this young lady, we have only 



24 FUNCTIONAL NERVOUS DISORDERS, 

the evidence of deterioration having gone so far as to 
diminish both the size and the temperature of the fingers, 
and to produce considerable pain in them. What has been 
the issue of the case I do not know. It was, before I saw 
it, invested with a great degree of anxiety, on the part of 
both the patient and her friends, for they had received the 
impression that she had a subclavian aneurism, which 
would require a very serious, and no doubt to her mind a 
very dangerous, operation." 

The following case, also reported by Hilton, shows the 
effect of transferred irritations in modifying the nutrition 
of a part : 

" Gray Hair on the Temple Depending on a Decayed 
Molar Tooth in the Lower Jaw on the Same Side. — 
A person was brought to me by a surgeon suffering very 
great pain on the left side of his face. He was much ex- 
posed to the weather, and suffered a great deal in conse- 
quence. He had taken many things to cure the neuralgia, 
as it was termed. I observed that he wore a wig, and I 
asked him the reason. He said, 'Curiously enough, the 
hair on my left temple has all turned gray. I did not like 
to have black hair on one side and gray on the other, so I 
had my head shaved, and wear a wig. ' Upon examining 
his mouth, I found he had a decayed and painful molar 
tooth on the left side of the lower jaw — supplied by the 
third division of the fifth nerve. The patch of gray hair 
appeared to me to be the effect of the nervous association 
of the auriculotemporal branch of this third division of the 
fifth nerve with the decayed tooth in the lower jaw. 
When this second molar tooth in the lower jaw was ex- 
tracted the neuralgic pain very nearly ceased. I have not 
seen the patient since, and cannot say whether the hair 
has recovered its color. All I can say is, it was stated to 
me, that during the time he was suffering extreme pain on 
the left side the hair over the temporal region became 
nearly white: a difference in color suggesting to myself 
some structural deterioration, and to the patient the pro- 
priety of having his head shaved and wearing a wig." 



THE REFLEX NEUROSES. 25 

The curious effect that fright and pain or neuralgia in 
a distant part has in causing the hair to turn gray sud- 
denly has been exemplified lately in my practice. Ten 
days ago I was asked to see Mrs. K., a lady of sixty-five 
years who had been knocked down by a cable car. The 
only injury she received besides a very great fright and a 
severe bruising was a painful injury to the back of the left 
hand. The daily dressing of the hand was performed by 
my assistant, who, like many other recent hospital and dis- 
pensary graduates, was not at all tender or sympathetic in 
his manipulation; moreover, the solution of bichloride 
of mercury and the mixture of ether and iodoform applied 
was an additional source of pain. The family and the 
friends of the patient state emphatically that before the 
accident she did not have a gray hair in her head. Now 
the vertex and frontal region is quite gray, the black and 
gray lying peculiarly in streaks. On the left side, the 
same side as the injured hand, the hair is very much 
grayer and covers a much larger surface, extending down 
on the side of the head much farther toward the neck. 
The hair on the back of the head and neck is very black. 
It has always been heretofore a subject of interest and re- 
mark to the family and friends that although sixty-five 
years old, Mrs. K. was entirely without any gray hairs. 

Another case with which I am acquainted is that of a 
young man whose wife was drowned in a freshet, where 
she was found among a lot of bushes. Her appearance 
was so terrible and the sight gave the husband such 
a shock that the hair of part of one side of his head 
and the eyebrow and corresponding half of his mus- 
tache turned perfectly white. These sudden modifica- 
tions of nutrition of a part are difficult to explain, espe- 
cially so when we consider the hair simply as an appen- 



26 FUNCTIONAL NERVOUS DISORDERS. 

dage to the body. Cases of sudden fright turning all the 
hair white in a single night are often reported. Mr. R. S., 
when a young man, was shipwrecked and floated in the 
ocean for forty-eight hours lashed to a plank. When 
found his hair had turned very white as a, result of the 
mental agony which he had undergone. 



CHAPTER II. 
THE CEREBRAL NEUROSES OR PSYCHOSES. 

There are peculiarities of the mind well known to every 
observer, which are often dependent upon morbid con- 
ditions of the abdominal and pelvic viscera. Of these the 
lighter and more common forms are : Mental depression, 
loss of memory, excessive irritability, wakefulness, or, on 
the other hand, intense lethargy and drowsiness during 
the daytime; morbid fears, such as of death, disaster, 
or insanity; hypnotism, trance, catalepsy, somnambu- 
lism, neurasthenia or nervous exhaustion, anaesthesias, 
globus hystericus, cardiac palpitations, joint neuroses or 
joint pains, amenorrhcea, enuresis, dyspepsia, and diar- 
rhoea coming on from bad news or "hard times." Under 
this head will come all the hysterical symptoms dependent 
upon the emotions, such as hysterical aphonia, hysterical 
apncea, hysterical laryngismus, hysterical suffocation and 
strangulation. The more severe types are melancholia, 
mania, and convulsions. 

It is not to be expected that we have included all the 
cerebral neuroses, but we will simply touch upon the more 
prominent and those most frequently met with. The 
question in my mind is, how to differentiate hysteria, which 
is generally dependent upon anaemia, from the neuroses. 
The cerebral neuroses often occur in neurotics from the 
mind being directed to a particular part ; this is seen in 
patients who are familiarly known as " womb cranks, " who 
imagine they have uterine disease, and are sometimes 



28 FUNCTIONAL NERVOUS DISORDERS. 

readily cured by almost any simple manipulation of the 
uterus. Many of these women have been cured by having 
a uterus "tipped into place" when it was never out of its 
normal position, while in others, local measures of any kind 
will not avail for the cure of the mental disorder. 

The influence of the digestive and sexual organs upon 
the mental functions is well known to all physicians, yet 
in the practical treatment this knowledge is not always 
used to advantage. A young woman of exceedingly happy 
disposition becomes despondent and discouraged, with a 
completely changed disposition. From being kind and 
agreeable she becomes offensive, peevish, and insulting. 
This mental state is the result of an exacerbation of diges- 
tive or uterine disease, and is in reality a reflex hystero- or 
gastric psychosis. In some cases it is so severe as to cause 
fixed delusions ; even in the milder forms these psychoses 
result in much domestic unhappiness. 

The psycho-neuroses such as melancholia, mania, and 
hysterical insanity, which are not in any way connected 
with organic disease of the cerebrum, are often benefited 
by operations and treatment directed to other organs of the 
body. Interesting cases in confirmation of this have been 
recorded by Dr. Fordyce Barker and other authorities. 

Very much can be done in the way of improving these 
functional disorders by the method of expectant attention. 
If the patients are thoroughly convinced that the physician 
is curing them, many of them readily get well under almost 
any form of treatment, but there can be no doubt, as every 
gynaecologist is well aware, that many neuroses of a severe 
character depend upon uterine and ovarian lesions which 
must receive attention. In puerperal mania and melan- 
cholia nothing favors the return of the mental faculties 
to the normal so much as the restoration to health of 



THE CEREBRAL NEUROSES OR PSYCHOSES. 29 

the pelvic viscera. Uterine involution will often start im- 
provement. 

A common time for cerebral neuroses or psychoses to ori- 
ginate is the first few weeks of married life. I have seen 
the worst cases of hysterical apncea dependent on a cica- 
trized lacerated cervix. Severe migraine resulting from 
ovarian inflammation or from indigestion is a most com- 
mon occurrence. 

The following case is instructive in this connection : 

Migraine, Hemiplegia, and Chorea, Dependent upon 
Uterine Irritation. — Mrs. Alice C, set. 18j r ears; menses 
came on first profusely when she was 13, lasting for four 
or five days. During her sixteenth year they became 
very scanty, lasting two days. This condition continued 
for about six months when severe pain of short duration 
started in the left ovarian region. Then, from overwork 
and worry followed by a mild attack of diphtheria, her 
present condition was developed. She suffered severely 
from chorea and was also very hysterical. The hemiplegia 
came on gradually six weeks after the attack of diphtheria, 
and involved the face and upper and lower extremity of 
the left side. The attack of hemiplegia lasted for three 
months. She was treated by medication and actual 
cautery applied to the back. The treatment helped the 
chorea but had no effect on the hemiplegia. There were 
no changes at this time in the menses, which were still 
scanty and painful. At the end of three months she took 
a short sea voyage (as far as Portland, Me.), which caused 
a complete disappearance of hemiplegia and chorea. About 
a month afterward, after a thirty-mile ride and a severe 
disappointment in a love affair, she had a slight return of 
the hemiplegia. Two months later, on her return to the 
city during the hot weather, she had a severe attack of 
right hemiplegia. She at present complains of occipital 
and temporal headaches. There is also severe pain in the 
cardiac region. Has had nasal hemorrhages at time of 



30 FUNCTIONAL NERVOUS DISORDERS. 

menses for several months and at other irregular periods. 
For the last few days she has suffered from nausea and 
morning vomiting ; is now pregnant. 

The hemiplegia continues on the right side ; its seat was 
formerly the left. She is excessively nervous ; her tongue 
seems to be thick and her speech is imperfect. Any se- 
vere annoyance will cause a fit of hysteria. Suffers also 
with migraine on the left side accompanying the morning 
vomiting. 

The functional character of the hemiplegia in the pre- 
ceding case is shown not only by its transference from the 
left to the right side, but also in a degree by its occur- 
ring at an early age, organic hemiplegia or paraplegia 
occurring usually at an advanced age or at the time of 
degenerative changes in the blood-vessels. Like chorea, 
functional hemiplegia is found during periods of develop- 
ment. 

Functional Paralyses. — There are many points of simi- 
larity in functional and organic palsies; it is, however, 
often easy to differentiate between the two. The functional 
variety is generally connected with the menstrual period 
and exaggerated by it, its intensity varying from time to 
time. These paralyses sometimes disappear suddenly, 
although as a rule the return to the normal condition is 
gradual. 

In speaking of functional and hysterical paralyses we 
should carefully differentiate between the two, calling only 
those hysterical in which the emotions play a part. The 
term hysteria ought to be confined to cases where distinc- 
tive hysterical symptoms are present, as there are many 
functional cases without apparent hysteria. In these cases, 
if we begin by rectifying the general health, the mind will 
of itself return to the normal state. If the intelligence and 
will power of the patient are enlisted in the treatment and 



THE CEREBRAL NEUROSES OR PSYCHOSES. 



31 



she uses them to help herself, the recovery is much more 
rapid. 

Muscular power is greatly diminished in hysterical 
cases. This is most pronounced in the extremities, espe- 
cially on the left side. 

When facial palsy is present it is generally on the side 




Fig. 4.— Hysterical Paralysis. 



Fig. 5.— Hysterical Contractur 




Fig. 6.— Crutch Paralysis. Fig. 7— Crutch Paralysis. 

From a Patient Falling Asleep with Axilla Resting on the Back of a Chair. 



of the involved limbs. Aphonia, due to palsies of the 
laryngeal muscles, is quite common, and the muscles of 
the pharynx and oesophagus have also been noted bv 



32 FUNCTIONAL NERVOUS DISORDERS. 

many observers as having been affected with hysterical 
paralysis. 

In the common forms of this disorder one limb, one side, 
or both lower extremities are involved. The attacks usually 
come on after severe mental excitement or a hystero-epi- 
leptic seizure. The paralysis may be partial or complete, 
and is usually accompanied by anaesthesia. 

Vesical paralysis is very frequently present in cases of 
hemiplegia and paraplegia, but rectal paralysis is much 
less common. 

Anaemic or functional paralysis depends upon qualitative 
changes in the blood and is often the result of severe dis- 
eases. The red blood corpuscles are diminished and the 
watery elements increased, with the result of affecting the 
motor functions of the nerve centres. 

Functional or anaemic paralysis has been seen after such 
exhausting diseases as typhoid fever, chronic diarrhoea or 
dysentery, bowel and uterine hemorrhages, chlorosis, dia- 
betes, scurvy, and malaria. Even in intestinal indigestion 
there is excessive weakness of the lower extremities accom- 
panied by cramps and pain. The paraplegia in these cases 
is due to a lack of arterial blood in the spinal cord. We 
should be careful to differentiate between functional and 
organic paralyses, such as come on from the arterial 
changes in syphilis or from embolism. The digestive tract 
and genito-urinary organs are generally the exciting 
factors, when diseased, of the functional or reflex paralysis. 
The irritation arising in these organs causes a contraction 
of the blood-vessels of the spinal cord which may lead 
eventually to an atrophy of the parts involved. Excessive 
irritation of the sensory fibres causes an arrest of the 
functions of the motor nerve centres. On careful exami- 
nation many of the so-called reflex or functional paralyses 



THE CEREBRAL XEUROSES OR PSYCHOSES. 33 

will be found due to pathological changes in the spinal 
cord. 

Eeheverria reports a case of ulceration of the cervix uteri, 
in which the application of a weak galvanic current, one 
electrode upon the symphysis pubis and the other upon the 
uterine cervix, produced violent pain and trembling in the 
legs, with paralysis for fourteen hours. 

Rosenthal reports a case of a girl, aged twenty-three, who 
suffered for three weeks from paresis of the legs coming 
on with pains and cramps in the abdomen. He found 
a needle deeply embedded in the vagina, and after its re- 
moval the paresis disappeared rapidly. 

In Nonat's case, loss of consciousness with paraplegia 
came on as the result of cauterization of the uterine 
cervix. 

Landry reports a case in which the paralysis disap- 
peared after the restoration of the deflected uterus to its 
normal position. 

The most common cause of functional paraplegia is irri- 
tation of the genital organs by masturbation or excessive 
venery. When from excessive coition, the paralysis comes 

on very suddenly. 
3 



CHAPTER III. 
SPINAL REFLEX NEUROSES. 

Changes in the uterus and digestive tract manifest them- 
selves by irritations throughout the whole of the spinal 
column, and in fact throughout the entire nervous system, 
and by the spinal and cerebral nerves all portions of the 
body respond to these changes. Many of the symptoms 
arising are readily noted by the laity : pains in the wrists, 
ankles, and fingers are often called wind pains, resulting 
as they sometimes do from irritations in the digestive tract 
when flatulence is present. 

Spinal irritation and spinal pains are quite character- 
istic of uterine disease, and the backache of weak diges- 
tion is a very common symptom. For a good example of 
spinal neurosis the case of Miss M. N., page 233, may be 
cited. 

Sympathetic pains occurring on the surface of the body, 
and having connection with affections of internal organs, 
are of great interest, as by them we can appreciate and 
locate organic changes and derangements of function of 
the internal portions of the body. 

The pain which occurs between the shoulders or over the 

inferior angles of the scapula is perhaps the most frequent 

of these " sympathetic" pains which we meet, and must 

be connected with the distribution of some of the spinal 

nerves, because there are no other structures which could 

give expression to the pain, and no other nerves occupy this 

position except the fourth, fifth, and sixth dorsal nerves, 

34 



SPINAL REFLEX NEUROSES. 35 

which are distributed over the interscapular space and the 
inferior angles of the scapulae. 

Hilton says : If we trace the great splanchnic nerve from 
within the thorax downward, and find it connected at its 
abdominal end with the solar plexus, thence trace its dis- 
tribution to the stomach, duodenum, liver, and pancreas; 
and if we follow the other or upper end of the same great 
splanchnic upward to the fourth, fifth, and sixth dorsal 
nerves, which give peripheral sensitive filaments to the in- 
teguments, over the angles of the scapulae, to the interscapu- 
lar spaces and the adjoining skin, one can well imagine that 
these nerves carrying the influence upward and backward 
may explain the occurrence of the pains sometimes expe- 
rienced in those external parts associated, with abdominal 
visceral disturbance. The pain which persons experience 
in disease of these viscera may be explained by the relative 
position of the great splanchnic nerve, communciating, on 
the one hand, with the solar plexus, and then with these 
digestive organs, and, on the other, distributing its 
branches to the fourth, fifth, and sixth dorsal nerves. 

In disease of the lower cervical, the dorsal, and the 
lumbar regions of the vertebral column the pain is usually 
expressed on both sides symmetrically. When the dis- 
ease lies between the occiput and the atlas, or between the 
first and second cervical vertebrae, this is not the case. In 
all cases of symmetrical pain the cause is central, or double, 
both sides being alike in a diseased condition. 

For instance, the positions of the sixth and seventh dorsal 
nerves are here indicated, as they are distributed to the 
skin just over the pit of the stomach. If pain be felt at 
that part alike on both sides of the median line, these 
nerves become the only possible expression of that cause, 
for there is no other structure there situated which could 



36 



FUNCTIONAL NERVOUS DISORDERS. 



manifest the pain. Then, tracing the nerves producing 
these surface pains backward to the posterior median line, 
and noting accurately the healthy or unhealthy condition 
of the various structures near which these intercostal nerves 
would pass — such as the ribs, pleurse, aorta, oesophagus, 

and other structures in the poste- 
rior mediastinum — we arrive at 
the vertebra and spinal cord, and 
in that way, by the law of exclu- 
sion, we arrive at the diseased 
spine as the real cause of the pains 
experienced at the pit of the stom- 
ach (see Fig. 8). 

In children bellyache is often 
the most prominent symptom in 
pleurisy or pneumonia. The at- 
tendant often concentrates his 
attention entirely upon the viscera 
under the upper half of the ab- 
dominal walls. This treatment is 
entirely misplaced, and blistering 
or poulticing the chest is the 
This is also an instance where the 
same nerves which supply the muscles supply likewise the 
skin over the muscles, and where the local manifestations 
are remote from the real cause of the symptoms. 

The Griffin brothers, of Limerick, in their exhaustive 
and valuable work entitled " Observations on the Functional 
Affections of the Spinal Cord and Ganglionic Nerves, in 
which their Identity with Sympathetic, Nervous, and 
Simulated Disease is Illustrated," published sixty years 
ago in London, draw the following conclusions : 

" 1st. That tenderness at one or more points of the spine 




Fig. 8.— Side View of Chest, 
Showing the Course of the 
Sixth and Seventh Dorsal 
Nerves. (Hilton.) 

method to be pursued. 



SPIRAL KEFLEX NEUROSES. 37 

is an attendant on almost all hysterical complaints, on 
numerous cases of functional disorder when the hysteric 
disposition is not so obvious, and in many nervous or neu- 
ralgic affections. 

" 2d. That many of the symptoms of these affections 
evidently depend upon a peculiar state of certain nerves, 
probably at their origin, may be reproduced at any moment 
by pressure, and are often relieved by remedies applied 
there. 

" 3d. That, in all cases of tenderness of the cervical and 
upper dorsal spine, there was nausea, or vomiting, or pain 
of the stomach, or affections of the upper extremities; but 
no pain of the abdomen, dysuria, ischuria, hysteralgia, or 
affections of the lower extremities. 

" 4th. That, in all cases of dorsal tenderness, pains affect- 
ing the abdomen, bladder, uterus, testes, or lower extrem- 
ities, were usual symptoms; while nausea, vomiting, or 
affections of the upper extremities were never complained 
of. 

" 5th. That nausea and vomiting appeared to have more 
relation to tenderness of the cervical spine, pain of the stom- 
ach to tenderness of dorsal; but that, when there was sore- 
ness of both, nausea or vomiting was still more frequent, 
and pain of the stomach scarcely ever absent. 

" 6th. That when several points or a great extent of the 
spinal column are painful and tender on pressure, local 
remedies are generally less effectual, and there is a strong 
disposition to transference of the disordered action from 
one organ to another ; the pain or tenderness in all such 
cases of transference shifting its place to a corresponding 
part of the spinal column, leaving the original point free, 
or with a very diminished degree of tenderness. 

" 7th . That spinal tenderness is seldom or never met with 



38 FUNCTIONAL NERVOUS DISORDERS. 

in cases of pure inflammation, except when these accident- 
ally occur in persons previously suffering from irritation 
of the cord ; and that, when appearances of inflammation 
present themselves in any organ, accompanied by a corre- 
sponding spinal tenderness, they cannot commonly be re- 
moved by the remedies applicable to inflammatory cases, 
and are often rendered worse by them. 

" 8th. That there does not appear to be a complaint to 
which the human frame is liable, whether inflammatory or 
otherwise, which may not be occasionally imitated in dis- 
turbed states of the cord; and hence that this disturbed 
state is one vast source of those complaints called hysterical 
or nervous. 

"9th. That those functional disorders connected with 
spinal tenderness are very often attended by some disturb- 
ance of the functions of the uterus, but that they are by 
no means always so, since they occur in those who are 
regular in this respect ; in girls long before the menstrual 
period of life, in women after it has passed, and, lastly, in 
men of nervous susceptible habits, and in boys. 

" 10th. That in fact they are not necessarily dependent 
upon any one organ ; since they are found indifferently 
coexisting with disturbance of the digestive organs solely, 
or the uterus solely, or of the circulatory or respiratory 
system. 

" 11th. That from the cases detailed we have reason to 
suppose spinal tenderness may arise from uterine disorders, 
from dyspepsia, from worms in the alimentary passages, 
from affections of the liver, from mental emotions, from 
the poison of typhus, from marsh miasmata, from erysip- 
elatous, rheumatic, and eruptive fevers, and from the irri- 
tation arising from local injury. 

" 12th. That it is almost invariably found in connection 



SPINAL KEFLEX LEUKOSES. 39 

with gastric or abdominal tenderness, in fever ; and this 
tenderness is probably like the soreness of the scalp, pains 
in the limbs, etc., dependent on a morbid state of the cord. 

" 13th. That, whether in fever or in other complaints, it 
is met with in the situation of the eighth or ninth dorsal 
vertebra much more frequently than at any other part of 
the spine. 

" 14th. That affections attended by spinal tenderness are 
seldom fatal ; that, even in those cases of intense irritation 
of the cord under which patients suffer extremely from 
pain for years, the event is generally favorable. 

" 15th. That they frequently, as well as hysteria, occur 
with all the appearances of a primary affection of the 
nervous system. 

" 1 6th . That affections are occasionally met with present- 
ing all the marks of the hysteric character, and perfectly 
resembling cases described as those of spinal irritation, but 
unattended by spinal tenderness or any other direct indi- 
cation of a morbid state of the cord." 

In one form of spinal irritation the hypersesthetic or 
hypersemic type predominates ; this is especially frequent in 
women. One of the first signs of the disease is weakness 
and weariness of the back and limbs. There is pain in the 
back, which is intermittent at first but afterward becomes 
very severe and constant ; it is usually located in the neck 
or between the scapulae; it occurs less commonly lower 
down. The spinal column is extremely sensitive to pres- 
sure, the pain is increased by exertion, by sitting erect or 
by bending of the body; from the irritated spine the pain 
radiates in .all directions according to that portion of the 
column which is affected. When the upper portion is in- 
volved, there is headache, insomnia, vertigo, nausea and 
vomiting, dyspnoea, palpitation of the heart, irritation of 



40 FUNCTIONAL NERVOUS DISORDERS. 

the diaphragm causing hiccough, heaviness, and soreness of 
the upper extremities. When it is the lower portion which 
is involved the abdomen, uterus, and bladder are affected 
by spasms and neuralgias; the lower extremities are often 
weak and cold. These neuralgias and motor disturbances 
are often of a migratory character. Along with the head- 
ache there is mental weakness; the patient quickly tires of 
intellectual effort. It is a chronic ailment lasting many 
weeks or months, the patient alternately improving and 
relapsing. 

Among the causes of this disorder are excessive stimu- 
lation of the emotions, over-excitement of the sexual organs, 
overwork and mental exhaustion, late retiring followed 
by early rising, anaemia, hydrsemia, and bad digestion 
resulting from bad air and unhygienic living. It is rather 
an obscure affection and difficult of diagnosis, distinguished 
from inflammatory affections of the cord by the non-ap- 
pearance of permanent anaesthesias and- paralyses, and by 
the absence of the sensation of a cord -like constriction 
around the abdomen, and of severe spasms and contrac- 
tures. There is no elevation of temperature and no marked 
muscular atrophy in this disorder. 

The treatment consists in improving the quality of the 
blood, giving easily digested nutritious food after correct- 
ing digestive disorders, and the administration of strych- 
nine, quinine, and iron in moderate doses. 

The hygienic surroundings should be looked to. Coun- 
try life with horseback or bicycle riding, should be recom- 
mended, but the exercise should not be carried to the point 
of severe fatigue. Hydrotherapeutic measures may be 
employed with advantage. Hot applications to the dor- 
sal spine are often of value. The foregoing methods of 
treatment should be used with caution, and measures, 



SPINAL REFLEX NEUROSES. 41 

particularly of a severe nature, should be tentatively 
employed. 

In the anaemic type of spinal irritation, weakness and 
exhaustion are the predominant symptoms ; pain is also 
present but is not severe or persistent. The patients tire 
very readily : after slight physical exertion, a short walk, 
ascending a single flight of stairs, standing for a short 
length of time, they are compelled to retire to bed. Sleep 
is unnatural and disturbed, and they generally feel as ex- 
hausted and prostrate on rising as they did on retiring. 
They are frequently hypochondriacal and suffer from a 
dread of fatal maladies such as paralysis, heart disease, 
consumption, etc., often having their hearts and lungs 
examined by physicians. Digestion in these patients is 
generally weak, and they usually suffer with cold hands 
and feet. This neurasthenic condition may last for many 
years and may sometimes even degenerate into organic 
disease of the spinal cord. Among the more common 
causes of this disorder is excessive irritation of the sexual 
organs, excessive insomnia, great mental exertion, and bad 
dietetic habits. 

The treatment should consist of forced feeding, rest, 
change of scene, abstention from sexual excitement and 
mental exertion. The food should be nitrogenous and easy 
of digestion. A stimulant of porter, ale, beer, or light 
wine should be taken with the food, and tonic drugs such 
as nux vomica, cinchona, and iron employed. Sea-bathing 
in great moderation is often of much benefit, as is the ap- 
plication of static electricity. The patients with these neu- 
roses are usually the daughters of wealthy neurotics who 
have exhausted their vitality in the struggle for money. 



CHAPTER IV. 
CARDIAC REFLEX NEUROSES. 

Stimuli arising from diseased states of the gastrointes- 
tinal or uterine organs are fully as powerful as the emo- 
tions in causing cardiac disturbance, and for this reason 
the cardiac neuroses are frequently dependent not only 
upon diseased conditions in the cranial, but also in the 
thoracic and abdominal, cavities. 

Among the cardiac neuroses are: (1) palpitations; (2) 
tachycardia; (3) bradycardia; (4) intermittent and irregu- 
lar heart action ; and (5) angina pectoris. 

Cardiac reflex neuroses are quite common; they take 
their origin not only in uterine and gastro-intestinal dis- 
turbance, and are frequently dependent upon an excitation 
of the emotions, but may result from severe cutaneous im- 
pressions. The intimate connection of the sympathetic 
nerves gives ample opportunity for the development of 
functional disorders of the heart. The most severe and 
important of these neuroses is pseudo-angina pectoris, not 
only on account of its frequency but from its close simu- 
lation of the true disease. In the functional form of the 
disorder there is no organic lesion present; the pain is of 
the same type and follows the same direction as in the true 
form of the disease, running down the left shoulder 
through the arm and hand. The attacks are not constant 
and there is frequent soreness over the region of the heart. 
In weak and hysterical women with this affection, the least 
exertion starts up an attack of palpitation with vertigo as 

42 



CAEDIAC REFLEX NEUROSES. 43, 

a result. Sometimes this continues for quite a time, with 
pain in the region of the heart, and breathing also gives 
more or less pain. Numbness in the arm and hand is very- 
frequent and neuralgic pains in the arm are often present. 
The palpitations are generally relieved by a few moderate 
doses of tincture of strophanthus. Women approaching 
the menopause are more liable to the disorder than at other 
periods, although it is common in dyspeptic girls. In the 
milder forms of the disease the attacks may last but a few 
seconds, the patient experiencing first a sharp pain similar 
to a "stitch" in the cardiac region. Simultaneous with 
these there is a sensation as if of suffocation. The patient 
finds it impossible to breathe. This continues and the pain 
in the heart becomes extremely severe. The left arm 
and hand twitch and seem to straighten out and become 
rigid. This entire process may only occupy a few seconds. 
The patient thinks while it lasts that death is imminent. 
During the attack the proper treatment is the hypodermic 
injection of either morphine with atropine, or ether, pref- 
erably the former. The use of each depends upon the 
pulse — a strong pulse indicating morphine while a weak 
one calls for ether. 

The cardiac neuroses dependent upon pelvic or digestive 
disorder have not hitherto received in medical treatises the 
amount of attention which their importance and frequency 
call for. In the treatment of the abdominal or pelvic dis- 
order upon which they depend, not only local but consti- 
tutional treatment is usually necessary. 

It is found that in some of these cases the emotions or 
sudden mental excitement will bring on severe attacks of 
flatulence when the patient has hitherto been quite free 
from it-. It often seems to be of a neurotic origin, and 
it is a debated question where the gas comes from. The 



44 FUNCTIONAL NERVOUS DISORDERS. 

flatulence is said to arise quite independently of fermen- 
tation. 

Some patients have a great deal more vitality than 
others; two individuals may apparently have the same 
amount of strength, but, as it has been aptly put, one has 
much better "timber" than the other, and consequently 
greater vital resistance to disease. The difference between 
the two manifests itself nowhere more completely than in 
the heart muscle, one withstanding all sorts of mental 
strain, physical hardships, and disease, without apparent ill 
results, and the other very readily collapsing under simply 
depressing influences. The pulse, respiration, and general 
aspect may, to our crude methods of observation, be appar- 
ently the same in both cases, yet one is on the verge of col- 
lapse. Many patients have a presentiment of impending 
dissolution. This is the result of the failure of vital forces 
manifesting itself to the individual by some curious mental 
process. I have seen a case of this kind in which the pre- 
sentiment was verified, the woman dying of concealed 
accidental hemorrhage. The same feeling occurs in severe 
cases of haemoptysis and hsematemesis. 

Dr. George W. Jacoby, in the New York Medical 
Journal for April 8th, 1893, states that in probably more 
than one-half of the persons suffering with motor disorder 
of the heart no anatomical lesion is discoverable ; he con- 
siders the subject one of great practical interest and divides 
the motor neuroses into the intermittent, irregular, those 
that are abnormally slow (bradycardia) and those that are 
abnormally frequent (tachycardia). In arhythmical forms 
of the disorder he states that the cause ought to be sought 
in some disorder of the digestive tract, and that it is ex- 
plicable by reflex through the vagus, and that a general 
neurasthenia is often present. 



CARDIAC REFLEX NEUROSES. 45 

Alcohol and tobacco are well-known factors in the pro- 
duction of these disorders. In bradycardia the digestive 
tract is credited with being the disturbing factor ; in tachy- 
cardia (which is not at all the same as palpitation) , the 
heart beat is perfectly regular but very rapid. It generally 
takes place in neurasthenic patients, as shown by the 
marked disorder of the urinary discharge, this sometimes 
being very excessive and at other times exceedingly 
scanty. Mental influences and digestive disturbances are 
placed as prominent factors in its production. In his valu- 
able article Dr. Jacoby states that he is quite convinced 
that the neuroses are often the precursors of organic dis- 
ease. He says : " So long as the equilibrium of the ner- 
vous system can be re-established after functional disorder, 
so long as repair out-balances waste, so long can we speak 
of functional disorder ; as soon, however, as waste is in ex- 
cess of repair, so soon do we have lesion, and with it 
organic disease. So in all these cases of motor neuroses of 
the heart, what to-day we may look upon as a pure neurosis 
may remain so for a period of time and then get well, or 
may develop into organic disease. Their prognosis, there- 
fore, is not to be estimated from the cardiac symptoms 
alone." This is my experience also in the motor neuroses 
of the heart and the cases of pseudo-angina pectoris which 
I have treated. We never know when they may show 
themselves as symptoms of organic lesions. 

The cardiac reflex neuroses are evidences in very many 
cases of a weakened heart muscle, and in some patients, 
especially those who are far advanced in years, there 
is a possibility of their being snuffed out at any time, 
the post-mortem showing probably nothing more than a 
slight enlargement with some minor degenerative changes 
in the heart muscle, no valvular lesions being present. 



46 FUNCTIONAL NERVOUS DISORDERS. 

The heart disorder is simply a part of the general arte- 
rial change, which includes all portions of the body and 
shows itself especially in the kidneys. 

Mrs. B., set. 26, is a thin, anaemic blonde, now con- 
valescing from her first confinement. On the fourth day 
after delivery I first saw this patient in consultation. 
Her pulse at this time was but 38 and regular; there was 
no sign of any disorder of the valves or of the heart muscle. 
Her appetite is fair, and the only discoverable troubles are 
a slight gastric irritation and pain and tenderness, not of a 
very marked character, in the region of the right ovary. 
She tells me that before becoming pregnant she suffered for 
a considerable time from leucorrhoea. On the eighth day 
after her delivery the pulse rose to 66 and after slight exer- 
tion was 72 for a short while, but fell again to 66. 

Mrs. B. K., 43 years of age, an anaemic blonde, has had 
seven children. During every pregnancy she has had 
frequent attacks of cardiac palpitation, has also suffered 
with heartburn and a considerable amount of flatulence. 
Attacks of nervousness and fear were also present, and the 
sight of water or (in winter) of the windows covered with 
frost, would induce an attack of this kind. In the middle 
of her last pregnancy an attack of la grippe caused a great 
increase in the number of these manifestations. The 
cardiac palpitations at this time persisted without inter- 
mission for four da} 7 s and nights (tachycardia). The 
attacks of nervousness and fear come on generally at 
night, but sometimes in the afternoon, with intense redness 
of the face. She is compelled to jump up and move around, 
as she cannot remain quiet while they are present. When 
the uterus is in the unimpregnated state she does not suffer 
from any of these disorders. This would point to a causal 
relationship between them, and would tend to show their 
reflex character. 



CHAPTER V. 
VASCULAR NEUROSES. 

The vascular neuroses are the vasomotor or those of the 
peripheral circulation. They may be general or local, ex- 
ternal or internal — external, as in a morbid blush, or in- 
ternal, as in a globus hystericus. 

Vasomotor neuroses are exceedingly complex phenomena, 
the causes and results of which are often difficult of eluci- 
dation. In giving them consideration one should remem- 
ber accurately the anatomy and physiology of the parts 
involved in their production. 

Among the more marked of the general vascular neu- 
roses is the hysterical or nervous fever mentioned below, 
usually resulting from some uterine or digestive difficulty. 
General nervous chills are also a vasomotor disorder de- 
pendent upon some local irritation, either cerebral, ab- 
dominal, or pelvic. Febrile conditions dependent on 
uterine disease are very common at the menopause; they 
often simulate malarial fevers, but are not benefited by 
quinine. Treatment directed to the uterine trouble often 
gives relief. In some cases they have their origin in ab- 
normalities of the menstrual flow. 

Among the local vascular neuroses we find flushes, 
morbid blushing, extreme redness of the nose and malar 
prominences, burnings of the palms of the hands, soles of 

the feet, top of the head, side of the chest, erythematous 

47 



48 FUNCTIONAL NERVOUS DISORDERS. 

eruptions, hemorrhages, sweats — sometimes unilateral or 
confined to the hands and feet — coldness of the extremities, 
dryness of the body. 

I have seen a number of cases of morbid flushing or 
blushing in my practice, and a few of them I have con- 
sidered of sufficient importance to justify me in taking- 
notes of them. In looking up the subject in medical lit- 
erature I could find but comparatively little bearing upon 
it. Dr. Harry Campbell, of London, published a rather 
extensive monograph upon this subject in August, 1890, 
and to it I am indebted for much information. 

The ganglionic system through the vasomotor nerves 
which control the circulation, and through which it trans- 
mits irritations in the same way as the cerebro-spinal 
system, is the important factor in these neuroses. Pallor 
and flushings show the contraction or dilatation of the 
vessels through this influence. That the mind is a great 
factor in many of these states, or that they are really psy- 
choses, is shown by the condition of excessive or morbid 
blushing. 

Sometimes the irritation reflected is general, as in con- 
ditions of neurotic fever or when nervous chills occur. It 
is said that in some cases of neurotic fever the temperature 
has even risen to over 110° F. Mental and nervous ex- 
citement will frequently run the temperature up to 104°, 
and this temperature will subside quickly without any 
treatment other than the removal of the original cause of 
excitement. Besides being reflected generally, it is some- 
times reflected locally or partially, as in cases of palsy of 
the extremities or of the face; or sometimes the disturb- 
ance is more marked, as is seen in cases of flushings of the 
abdomen. 

Morbid flushing at the menopause is very frequent as a 



VASCULAR REFLEX NEUROSES. 49 

result of genital disease, but in very many cases I am con- 
vinced chronic gastro-intestinal catarrh is a still more im- 
portant factor in lowering the tone of the nervous system. 
In these cases the gastro-intestinal canal needs treatment 
more often than the uterus. In cases of morbid flushing 
salivation is frequently present. This is, of course, a 
glandular neurosis, and it shows the interdependence 
and identity of the different forms. It must not be con- 
founded with salivation from the too free administration 
of mercurials. The latter maybe due to the teeth contain- 
ing many fillings of cheap mercurial amalgam instead of 
gold or silver. Dentists claim that this is a not uncom- 
mon cause of mercurial salivation, and it should always be 
borne in mind when this symptom is observed. A flushed 
and congested face with a red and swollen nose is a frequent 
gastro-intestinal vascular neurosis or dermatosis. The so- 
called " chronic erysipelas " of the face is a vascular der- 
matosis and comes under the head of dermal neuroses. 
Excessive perspirations are glandular neuroses, but they 
are of vasomotor origin. It is very difficult to separate 
and classify these neuroses, as they are so commonly found 
associated in the same patient, and they are also so in- 
timately interconnected. 

The red nose and flushed cheeks due to reflex vasomotor 
disorder are a source of great mortification and mental dis- 
tress to those so affected. It is a most disagreeable afflic- 
tion, especially to women. It has been generally consid- 
ered by the ignorant as a sign of alcoholic indulgence : 
more often it is due to gluttony and gastro-intestinal dis- 
ease from overfeeding and high living. Particularly in 
small provincial towns many persons have been condemned 
as secret drinkers when they were simply suffering from 
a gastro-intestinal catarrh, secondary possibly to a post- 



50 FUNCTIONAL NERVOUS DISORDERS. 

nasal catarrh, which was unfortunately manifested in a 
disordered state of the vasomotor nerves of the face. Bad 
cooking and general unhygienic living are the usual causes 
of this condition in women. As an instance of the way 
the ignorant look at it, I may quote a remark in this con- 
nection which I overheard a rough fellow make : " If they 
don't drink they should take in their sign." That the 
ignorance is not all confined to the poorer classes is shown 
by the dietaries of those in higher life. Extreme cold- 
ness of the extremities is a very common vascular neu- 
rosis due to abdominal or pelvic disease, and indigestion 
is fully as frequent a factor in its causation as uterine 
congestions. 

There are also patients who suffer from extreme pallor 
of the face whenever excitement causes the heart to beat 
furiously. Some of these local vascular neuroses become 
chronic and exist as dermatoses, like acne rosacea and 
chronic urticaria. Upon the disappearance of the local 
disease these reflex disorders cease to exist. The flushed 
appearance is, in many of these cases, due to a vasomotor 
paralysis. Some of these patients will frequently have 
the upper portion of the body in a constant flush, while the 
feet will be cold as ice. Insomnia is here often present, 
sometimes of such a severe type as to lead to mild forms 
of mental aberration. Vasomotor paralysis, causing burn- 
ing sensations at the vertex and occiput, is a very common 
symptom of uterine or ovarian disease. Coldness of the 
extremities is not only present in disorders of the uterus 
and anemic conditions, but is a common symptom of other 
abdominal difficulties, such as indigestion and "bilious- 
ness." Very many patients with indigestion have numb- 
ness and coldness of the left side of the body, which is often 
very marked, the heel and the tips of the toes and fingers 



VASCULAR EEFLEX NEUROSES. 51 

on the left side being sometimes excessively cold. Even 
the novelists note the vasomotor changes dependent upon 
mental disturbances when they speak of a heroine's face 
blanching and of her " shivering and becoming cold with 
nervous excitement." 

In hemicrania and similar vasomotor neuroses the arteries 
may undergo spasmodic constriction, thus shutting off the 
blood supply and rendering the parts pale and anaemic ; or 
there may be dilatation of the vessels with hyperaemia of 
the part. Sometimes these conditions alternate : there is 
constriction followed by dilatation, and a consequent 
blanching followed by a suffusion of the part affected. 
These cold sensations and hot flushes of the skin are most 
commonly seen at the menopause when uterine or digestive 
disease is present, but may occur at any time. Either of 
these two conditions continuing for a considerable space of 
time results in marked nutritive disturbance of the parts 
involved. In the anaemic type the parts are pale and an- 
esthesia is present. In the hyperaemic type there is warmth 
and redness of the part with some slight hyperesthesia; 
the glands involved are stimulated and there is increased 
secretion. Profuse perspiration may, however, take place 
in this disorder without any other symptoms being appar- 
ent to the observer. Irritations of the plexuses and fila- 
ments of the sympathetic and cerebro-spinal systems from 
disease in the abdominal or pelvic cavities start up many 
vasomotor disturbances in distant parts of the body. The 
numbness with tingling present in the left arm in attacks 
of angina pectoris is a good example of a reflex vasomotor 
neurosis. Vasomotor neuroses of this spasmodic variety 
may also depend, upon ovarian irritation. If the causa- 
tive lesion is central, as in a case of endometritis, we maj" 
find both the lower extremities affected by a change in the 



52 FUNCTIONAL NERVOUS DISORDERS. 

vascular supply and in the sensation of the parts, frequently 
causing reflex paraplegia. 

Mrs. T., set. 76, has had attacks of angina pectoris. 
Her left arm is considerably weaker than the right and 
at times is painful, particularly in the centre of the palm 
and the front of the elbow joint, with numbness and 
tingling of the fingers; the arm is cold, but its nutri- 
tion does not seem to be impaired. Only by the most care- 
ful examination can the pulsation be detected in the radial 
artery at the left wrist, and it is impossible to count it ; 
the pulse in the right radial is very strong. When she 
was very much younger, she says, her physician never 
noted any special difference between the pulsations of the 
two radials, or, if he did, which is more likely, he never 
spoke of it. She had suffered since girlhood with cardiac 
weakness. In some patients this condition of spasmodic 
contraction of the blood-vessels is temporary when depend- 
ent upon abdominal or pelvic disease, and disappears 
readily on removal of the causative lesion, the pulse in 
both arms, and probably in both feet, in many cases be- 
coming equal in strength. 

Morbid flushing, as a vasomotor disturbance, is due often- 
times to want of tone in the surface vessels, which thus 
causes either great pallor or flushing of the part. It is 
this w T ant of tone also in the deeper vessels which probably 
causes the congestive and ansemic types of neuralgic head- 
aches, and there are, I believe, undoubtedly extreme states 
of pallor or flushing of the cerebral tissue, the same as we 
frequently see on the surface of the skin. Areas of pallor 
in the brain may give rise to symptoms like ansemic roar- 
ing, snappings, whistlings, etc. These patients frequently 
have anaemia of all the extremities, suffering intensely 
from cold hands and feet. There can be no doubt that the 
intracranial blood pressure is to a degree under the control 



VASCULAR REFLEX NEUROSES. 53 

of the sympathetic nervous system, the same as the blood 
supply in other parts of the body. In considering the 
sympathetic system and its connections we need simply 
outline the circulatory apparatus, as in this department it 
manifests its greatest changes. Excessive emotion, shown 
by morbid blushing, is due in many cases to a weakened 
condition of the sympathetic nerves and to anaemia result- 
ing from fatigue, insufficient sleep, and exhaustion. 
Morbid blushing, although not, strictly speaking, a serious 
disorder, is, to say the least, extremely disagreeable to 
the victim. It is simply the manifestation of a weakness 
in the nervous system. It is not the symptom of blushing 
which needs treatment, but the general condition which is 
at the basis of the disorder. Probably the most prominent 
exciting cause is self-consciousness, either by introspection 
or by the attention being drawn to the external portions of 
the body while under examination by others. 

If a modest individual of extremely nervous tem- 
perament is in company with a number of persons, and 
imagines that the people around her are regarding her 
critically and are entertaining rather a disparaging opinion 
of her, she is very liable to manifest her abnormal self- 
consciousness by blushing, or even by becoming embar- 
rassed in her conversation, and stammering. Shy and 
nervous persons blush readily when attention or remarks 
are directed to their personal appearance. Women are 
said to suffer more frequently than men from this disorder ; 
but there are many men whose nervous system is disor- 
dered, either congenitally or by exhausting mental or 
physical work, who are much given to blushing and other 
manifestations of nervous weakness. The young blush 
much more pronouncedly than those who are older, not 
only on account of the texture of the skin being more deli- 



54 FUNCTIONAL NERVOUS DISORDERS. 

cate and healthful, but from inexperience and on account 
of their condition of hypersensitiveness not having as yet 
been blunted by continued contact with the world. Blush- 
ing is generally confined to the face, on account of its ex- 
treme vascularity, and therefore, having a greater supply of 
vasomotor nerves, emotional disturbances manifest them- 
selves more prominently in that part, the face being the 
portion of the body most exposed to view and upon which 
most attention is concentrated in looking for recognition, 
or in studying character or discerning beauty or homeli- 
ness. The self-attention thus given the face makes it 
abnormally sensitive and the vessels extremely prone to 
dilate, with blushing as a result. 

It is said, among nations where other parts of the body 
are exposed to view, that blushing is by no means confined 
to the face, but is much more widely diffused. 

Many people blush more readily before strangers than 
before acquaintances, though sometimes the opposite is the 
case. In some individuals the blushing takes place at 
regular hours, and with many it is so severe that it actually 
prevents them from going into society. Blushing rarely, 
if ever, occurs in solitude or in darkness ; it occurs only 
when observation is directed toward the personal appear- 
ance, and then results from embarrassment and self-con- 
sciousness. Anything which lowers the tone of the ner- 
vous system tends to the development of functional nervous 
disorders, of which excessive self-consciousness is a type. 
Many cultivated and scientific men are prone to blush in- 
ordinately from humility and diffidence, having a low 
opinion of their own ability, while the ignorant egotist is 
never known to blush. That colored people blush has been 
proven by scars on the face changing color under condi- 
tions which would induce blushing in those who are white. 



VASCULAR REFLEX NEUROSES. 55 

Blondes exhibit a tendency to blushing, when the skin is 
healthy, much more vividly than do brunettes with sallow 
skins, although it is quite probable that dark-haired ladies 
blush with fully as great frequency as those who are light. 
It is more common in those of delicate nervous organiza- 
tions, while those of coarse natures are very little affected 
by it. 

In attacks of excessive self-attention, where there is a 
difficulty in concentrating the thoughts, the one idea be- 
comes unduly prominent and morbid blushing results. 
Some people blush on the slightest occasion. A case is- 
noted of a telephone clerk who blushes even when convers- 
ing through the telephone. Some men cannot go into shops 
where there are women without blushing intensely. Many 
clerks are victims of blushing, and, as a result, suffer much 
mental distress while serving customers. Teachers blush 
before their pupils, and men before their wives. Lovers 
blush frequently and painfully in the presence of their 
future partners. Lawyers are about the only class to whom 
this annoying affection is unknown. A grizzled old sea- 
captain, who passed many years in command of passenger 
ships crossing the Atlantic, invariably became much em- 
barrassed and blushed hotly when addressed by young and 
handsome lady passengers. Blushing is much more fre- 
quent in old men than in old women. 

Predisposition to blushing, like other peculiarities in 
individuals, is frequently inherited. Darwin calls atten- 
tion to a case of inherited blushing which came under the 
observation of Sir James Paget. While conversing with 
a young girl "a big splash appeared, first on one cheek, 
and then other splashes variously scattered over her face 
and neck. He subsequently asked the mother whether her 
daughter always blushed in this peculiar way, and was 



56 FUNCTIONAL NERVOUS DISORDERS. 

answered, 'Yes; she takes after me.' Sir James Paget 
then perceived that by asking this question he had caused 
the mother to blush, and she exhibited the same peculiarity 
as her daughter." 

Many of these inordinate blushers are timid and melan- 
cholic, sometimes to a degree bordering upon a mild form 
of mental aberration. They seek solitude and are exces- 
sively sensitive about people they meet, who they may 
fancy are criticising their personal appearance. For this 
reason they are so shy that they dislike meeting friends or 
strangers in the street. Many of the victims of this dis- 
order, if relating an incident or anecdote, will often lose 
the thread of the story by their concern as to what their 
auditors may be thinking of them. 

The best cure for this condition of excessive self-con- 
sciousness is a constant and free intermingling with others 
in the work of life. Solitude is a great factor in the pro- 
duction of self-consciousness. Poverty and worriment are 
also elements in the causation of excessive shyness. 

The preventive treatment of this condition should be 
begun in childhood, by sending the children to large public 
schools where they will be allowed a considerable amount 
of freedom from restraint and come in contact with a 
coarser and rougher element. This will tend to make them 
bolder and more self-reliant. Children who seem to be 
afflicted with shyness and inherit a morbidly sensitive 
nervous disposition, should at a very early age be instructed 
in elocution and encouraged, or in fact compelled, to fre- 
quently give recitations before their classmates. It is also 
well to have them taught music and singing, the exhi- 
bition of which accomplishments before friends or class- 
mates will materially tend to remove the predisposition to 
shyness when present. It is said that many coquettes have 



VASCULAR KEFLEX NEUROSES. 57 

the power of voluntary blushing. This is likely to be true 
in some instances, as the smaller blood-vessels of the face 
may probably be influenced through the nervous system to 
a certain extent. Blushing often depends on certain emo- 
tional influences. When these influences are but slight 
the blushing may be extremely evanescent; when the 
emotional changes are very marked the blushing may be 
very intense. Blushing is the external manifestation of 
the internal emotional perturbation, and its extent is gen- 
erally in proportion thereto. Some women, instead of 
blushing when suffering these distressing emotional dis- 
turbances, become absolutely pale. The blush may be 
preceded by very little disturbance, or it may be ush- 
ered in by a warm glow over the whole body. In severe 
cases the mental confusion is very marked, the heart throbs 
violently, there is a sensation of suffocation, and the breath 
becomes short. There is a peculiar sensation at the epi- 
gastrium, often followed by the condition of globus hys- 
tericus or constriction of the throat. 

Palpitation of the heart is a very common condition 
immediately preceding the act of blushing. Many blush- 
ers experience a feeling of dread as part of the emotional 
state. The dread, breathlessness, speechlessness, and glo- 
bus hystericus are all depressing emotions, and are often 
accompaniments, in a greater or less degree, of the actual 
blush. 

When the blushing is of a severe type there is always 
mental confusion present. In a large number of cases the 
individual completely loses the power of thought for the 
time being. The mind is completely paralyzed, and, in 
popular language, she is "covered with confusion," or, in 
slang parlance, "rattled." There is an instinctive desire 
for self -concealment. The blusher either averts the head 



58 FUNCTIONAL NERVOUS DISORDERS. 

or looks downward. The expression, " I wished I could 
have sunk through the floor," which we have heard used, 
aptly expresses the mental condition of the patient at this 
time. The overworked cultured classes have, as a rule, 
more self -consciousness than the uneducated, but they have 
more power to restrain its manifestations. They very 
rarely meet your gaze directly, and while conversing 
habitually look at some adjacent object, merely bestowing 
occasional side glances on the person with whom they are 
conversing. It is almost impossible to compel any of the 
lower animals to look one in the face and eyes even for a 
very short space of time. Especially is this the case with 
the dog, whose head you cannot possibly hold still for a 
few seconds while looking into his eyes. 

In some cases of very violent blushing the face becomes 
bathed in perspiration. In some women it is so severe 
that it is followed by a well-marked rash which not only 
covers the face, chest, and neck, but may extend to the 
hands. The blush is often followed by pallor of the face ; 
this is due to constriction of the blood-vessels — a reaction 
following their dilatation. Morbid blushing occurs most 
frequently in women exhausted by anxiety, the eating of 
improperly cooked foods, bad air, and overwork. The 
blood of these patients is usually anaemic. When a person 
has once suffered from this disorder he is liable to have 
subsequent attacks, as the nervous system is highly im- 
pressionable, and the condition once well developed is 
apt to be perpetuated by slight influences, such as dis- 
ordered digestion. 

Irritations arising in the digestive organs are probably 
the chief causes of the nervous depression which accom- 
panies these conditions. The impure blood resulting from 
the bad digestion produces most deleterious influences on 



VASCULAR REFLEX XEUROSES. 59 

the nervous system, thus starting up a great variety of 
functional disturbances, of which morbid blushing is a 
good type. Many of these tendencies to weakness of the 
digestive and nervous system are inherited. An impor- 
tant factor, therefore, in the treatment of these conditions 
is the enrichment and purification of the blood by dietetic 
and hygienic means. As already stated, education is a 
great factor in the treatment of hereditary nervous weak- 
nesses, and this educational treatment should be begun at 
a very early age, when the first demonstrations of excessive 
shyness, which is part of the nervous weakness, are noticed. 
Otherwise it is liable to increase in severity until it be- 
comes an actual disease. 

Skilful care and treatment will do much toward remov- 
ing this condition of weakness. Habits of solitude and 
self -communing should be discouraged and the child should 
be forced to mingle freely with other children, which has a 
very wholesome influence and tends greatly to the modifica- 
tion of any peculiarities of disposition. In the adult the 
treatment is more difficult. Everything which contributes 
to elevate the tone of the nervous system should be adopted. 
Nothing is more important in these cases than the im- 
provement of the general nutrition. These neurotics, 
without exception, suffer from anaemia. Therefore the diet 
and regimen require special supervision. Rest, mental 
and physical, with proper hygienic surroundings and 
forced scientific feeding, will probably cure the majority 
of cases. In some of the severer types massage, tonic 
baths, and electricity are indicated. Many of these cases 
begin with dyspepsia, resulting often from post-nasal 
catarrh. The social instincts should be cultivated and 
every possible effort made to enjoy life. In this state 
the nervous centres are exhausted and must be built up 



60 FUNCTIONAL NERVOUS DISORDERS. 

again by th-e enriched blood. Change of climate to a 
higher altitude is often useful in these cases as a stimulant 
to digestion and nutrition. It is in this way that advan- 
tage is derived from a trip to the Adirondack region or the 
Rangeley Lakes in Maine. Out-of-door exercise, as in the 
treatment of all functional nervous disorders, is of the 
greatest utility. It has a most favorable influence on the 
general health. Wind and sun, having a tanning influ- 
ence on the skin, which will render the blushing less re- 
markable, should be courted as much as possible when 
taking outdoor exercise. During attacks of blushing relief 
is often obtained by lying down ; they then gradually dis- 
appear under the influence of rest. An irrational method 
of living, by which there is no regularity in respect of 
food, exercise, and rest, is the cause of most of the weak- 
ness of the nervous system in these individuals. This is 
more particularly true among the poorer classes. The 
women, looking after the wants of the household, see that 
the other members of the family get food, but neglect to 
supply themselves in a proper manner ; they thus soon be- 
come victims of digestive disorders and drift into chronic 
invalidism. Fried meats, pastry and pickles, strong tea, 
coffee, and wines, are all agents in retarding the digestion 
and impoverishing the blood. Morbid blushing is often 
caused by bad digestion. The irritative action of wines or 
other alcoholic drinks on the mucous membrane of the 
stomach reflexly causes flushing of the face. 

Cold bathing is preventive and also exercises a curative 
influence on this state; but as in many cases the cold bath 
is injurious and cannot be tolerated, the patient should be 
gradually trained to resist its depressing influence. The 
bath should be first given tepid and the temperature grad- 
ually lowered in each succeeding bath. The immersion 



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VASCULAR REFLEX NEUROSES. 61 

should be of very short duration, and should be imme- 
diately followed by vigorous friction with a coarse towel 
or a flesh-brush or bath-glove, and finally the application 
of the warm bare hand until the entire surface of the 
body glows. Hot baths are often ver} 7 beneficial to ner- 
vous patients and are best taken before retiring. 

Electricity is of considerable advantage in these cases 
of nervousness ; mild galvanism should be applied daily for 
a short time only. 

If the face is heated and reddened by sitting in close 
proximity to the fire or by bathing it in very hot water, it 
will give immunity from blushing for a very considerable 
time. 

Many drugs are of great advantage in this disorder, 
notably iron, quinine, camphor, and turpentine. Stimu- 
lants are very disadvantageous and should be avoided as 
much a possible. 

Vasomotor Disorder. Abdominal Flushing. — Mrs. 
A. E. (see plate), 40 years of age; seven years married, but 
never pregnant. She has been ailing ever since her mar- 
riage. Before this she worked hard at monthly nursing. 
For several years past she has suffered from constant pain 
in the lumbar region posteriorly. Frequently suffers from 
severe pain and a sensation of burning in the vertex, neces- 
sitating the use of local applications for relief. Feels con- 
stantly fatigued and is compelled to lie down frequently. 
Has " no ambition or appetite. " For years past she has not 
taken any breakfast, with the exception of three or four 
cups of strong coffee. During menstruation nothing is 
retained on the stomach except the coffee. Now menstru- 
ates every two weeks, and during these periods the ab- 
domen becomes swelled and assumes a dark or bluish-red 
color and feels very hard; at the same time the lower 
extremities are " just like death, cold and clammy." There 
is also severe abdominal pain and the face is exceptionally 



62 FUNCTIONAL NERVOUS DISORDERS. 

red and hot. She feels feverish and thirsty, and has " fever 
sores" about the nose and mouth. There is also inconti- 
nence of urine, and the urine is scanty by day but excessive 
by night. During menstruation the bowels do not move, 
even after enemata. The tongue is coated with a whitish- 
brown fur. During her menses she is compelled to remain 
in bed, and during her last period was delirious and tore 
her hair out in handfuls. 

Vasomotor paresis of the lower extremities sometimes 
takes place in the nervous and hysterical, in which the 
legs become extremely hard and engorged almost to burst- 
ing. This also occurs at times in the hands or face. In 
speaking of a case of this type where the abdomen was the 
seat of the disorder, Dr. Weir Mitchell says : " The last 
case of hysterical vasomotor manifestations which I shall 
quote was so amazing that if I had not had the good for- 
tune to see it over and over, and to show it once to my 
friend Dr. William V. Keating, I might reasonably have 
hesitated to tax the credulity of my hearers. 

" Some twenty years ago I attended a young married 
woman whose life was embittered by losses of property and 
by the ill treatment of her husband, who finally deserted 
her. For a long period she exhibited, at times, hysteric 
disorders in the form of spasms, rigors, hemipalsies, and 
at last, for a month or two, moderate maniacal excitement. 
With favoring circumstances she at last got well, and re- 
moving to the West was lost sight of until about ten years 
ago, when I was called to see her at a hotel in Philadel- 
phia. At this time my patient was 35 years old, was 
irregular as to her monthly flow, and had, as I found, a 
womb tilted forward but not diseased, and no ovarian 
tenderness, or, at least, no tenderness of belly which was 
not the same everywhere. She was rather pale and very 
thin, and had a relaxed pendent abdomen marked by the 
scars of four pregnancies. I could find no disease of heart, 



VASCULAR KEFLEX NEUROSES. 63 

lungs, or kidney. She gave me this brief history : After 
some years of ease and comfort she had been led to risk 
her property in a wild speculation which ruined her, and 
now she was keeping a boarding-house in New York and 
was doing well, or likely to do well, except for the strange 
malady for which she came to consult me. After her new 
misfortunes she had some hysterical troubles, but these 
ceased to annoy her, and she began to observe that at or 
about the time of her menstrual flow, and afterward at any 
time, she was liable to have an enlargement of the belly, 
which did not seem to her to be due to wind, as with that 
form of swelling her previous experience had made her 
but too fully acquainted. The trouble became by degrees 
worse, and at last was so extreme as to cause certain un- 
pleasant feelings and to subject her to suspicions of being 
pregnant. 

" The swelling was certainly caused at times by emotion. 
It began at any time, rarely at night. Within a few 
hours the belly, in place of being flaccid and pendent, was 
swollen enormously. She looked, in fact, as a woman, 
thin as she was, would have looked at the eighth month of 
pregnancy. Other attacks were less severe, but alwa}'S 
they lasted for some hours before she could stand up, and 
it was usually a week before she was well. 

"When I saw her an attack was at its worst. The 
woman's pulse was about 165 and was a mere thread, at 
times imperceptible. Her face and limbs were white and 
cold. The abdomen was tense and red and could be felt 
to throb distinctly, while all over it the vessels, veins, and 
arteries were visibly enlarged. On listening over the 
belly I could hear a humming noise, a slight thrill. The 
chest itself was not quite so pale as the neck or face, but 
the breath was difficult and rapid. It was clear that, 
owing to palsy of all the abdominal vessels, all the avail- 
able blood of the body of a too bloodless woman was for a 
time in this cavity and its walls. If while in this state 
she sat up she instantly fainted, and it was difficult even 
to lift her head because of the symptoms thus caused. She 



64 FUNCTIONAL NERVOUS DISORDERS. 

herself complained of the tension of the belly and of the 
distressing pulsation within it. 

" The day after, the abdomen was certainly a third less, 
and it was then seen by Dr. Keating, who, like myself, 
could give no other explanation of the. condition seen than 
the one I have just mentioned. After a week the belly 
became nearly as flat as usual and I then ceased to see my 
patient. I learned from her some years later that by slow 
degrees she had become well of this singular malady." 

A former United States Senator from Rhode Island was 
noted as exhibiting a peculiar phase of morbid blushing 
during his forensic efforts : his face seemed to be divided 
into thirds ; the centre of the face from forehead to chin 
would become extremely red, while his ears and the sides 
of his cheeks would exhibit the opposite condition of ex- 
treme pallor. 

Morbid Flushing — Vasomotor Disorder after Hemi- 
plegia — Diabetes — Dietetic Treatment — Becovery. — 
Mrs. K. (see plate, Fig. 6), 68 years of age. About twelve 
years ago she had an attack of hemiplegia on the right side. 
She can see but very little with the right eye. Whenever 
she takes a small quantity of tea it sends the blood to one 
side of the face, accompanied by a tingling sensation; 
coffee has no such effect. This also occurs when she is 
excited and when busily engaged in mental work. This 
she has learned to look upon as a warning to desist from 
excitement or mental strain. She is often kept awake at 
night from nervousness excited by the burning and tin- 
gling. The patient is very stout and suffers from the fat 
form of diabetes. Under dietetic treatment, both liquid 
and solid, the sugar has disappeared from her urine and 
she is now in fair health. 

Functional Vasomotor Disorder — Unilateral Flush- 
ing. — M. F. (see plate, Fig. 4) , aged 20, single. Seen Janu- 
ary 1st, 1892. Strong, tall blonde. Unilateral flushing 
of right side of face. It came on first three months ago, 



M?GiUicuddy.-Plahe II 





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Fig. 3 



Fie. 4 




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CASES OF MORBID BLUSHING. 



VASCULAR REFLEX NEUROSES. 65 

eight days before menstrual period, and was coincident 
with an attack of leucorrhoea. Has also occurred from 
three to eight days before menstrual period. Her face is 
pale at first, but gradually gets red until most of right side 
is extremely so, the left side remaining pale. The redness 
disappears as the menstrual flow comes on. 

Nervous Unilateral Flushings and Indigestion. — 
Mrs. A. Z. (see plate, Fig. 5), 27 years of age, has had 
two children. She is extremely nervous, especially after 
a hearty meal. When digestion is slow, as it usually is, it 
is generally accompanied by palpitation of the heart. She 
had malaria when in the country five years ago. She was 
well up to that time. Her indigestion is accompanied by 
flatulence and eructations, but these are not very severe. 
Two weeks ago she was seized with a very severe head- 
ache. This was similar to those she had had at every 
menstrual period for the past five years. Occasionally a 
period is not accompanied by this headache, but if so the 
headache is much worse at the next period. They are 
migrainous in character and are generally located in the 
right temple. At times she suffers from severe gastralgia, 
which is most noticeable when a storm is approaching. 
For the past two weeks the scalp has been exquisitely 
tender and the hair has come out freely in combing it. 
At present her headaches are mostly occipital. She is 
frequently troubled with unilateral flushings of the face 
(left side), accompanied by dizziness and vertigo. 

The vasomotor neuroses are such complex phenomena 
that a correct appreciation of the vasomotor nerves and 
their physiological action, as well as the anatomy and 
physiology of the arteries with which they are connected, 
is essential to their proper understanding. 

Dr. Charles N. Smith, in an article on " Vasomotor Neu- 
roses of Pelvic Origin" in the American Journal of 
Obstetrics, November, 1890, says that "arteries over one 
one-hundredth of an inch in diameter have walls com- 



66 FUNCTIONAL NERVOUS DISORDERS. 

posed of an internal, middle, and external coat. The in- 
ternal coat is of the same structure throughout the whole 
arterial system, irrespective of the size of the vessel. It is 
thin, elastic, and identical in structure with the endocar- 
dium. The external coat, of white, inelastic fibrous tissue, 
varies but little in structure in the three sizes of arteries. 
The structure of the middle coat, however, is found to vary 
considerably with the size of the vessel. In the arteries 
of largest size the middle coat is formed almost exclusively 
of yellow elastic tissue, with but few muscular fibres. 
This middle coat gives to these largest vessels great elas- 
ticity; but, owing to the absence of muscular fibres, they 
possess little or no contractility. In the medium-sized 
arteries the yellow elastic tissue gradually disappears, its 
place being taken by muscular fibre. In the arteries of 
smallest size no yellow elastic tissue whatever is found, it 
having been entirely replaced by muscular fibre. In 
arteries less than one one-hundredth of an inch in diameter 
the inelastic external coat disappears, leaving but two 
coats in the vessel wall — the internal, and an external 
formed entirely of muscular tissue. 

" It will be seen, then, that the principal difference 
between the three sizes of arteries lies in the middle coat, 
and that, while the largest arteries have practically no 
muscular fibres, these fibres increase in number as the 
arteries diminish in size, until they alone form the whole 
of this coat. This muscular tissue is of the unstriped or 
involuntary variety, arranged in circular fibres surround- 
ing the vessel, with a few fibres arranged in a longitudinal 
manner. The presence of these circular muscular fibres 
gives to the arteries of medium and smallest size great 
contractility — a power not possessed by the largest- sized 
arteries. By relaxation of these fibres the arteries are 



VASCULAE REFLEX NEUROSES. 67 

dilated to their widest extent, allowing a correspondingly- 
increased amount of blood to pass through them. By con- 
traction of the fibres the lumen of the arteries can be so 
narrowed that but a limited amount of blood can circulate 
through them. 

" The contraction and dilatation of these muscular fibres 
are regulated by nerve ganglia and fibres known as the 
vasomotor ganglia and nerves. In the arteries of largest 
size, there being no muscular tissue, we find no nerve fibres 
distributed to their walls, although the nerves follow them 
in their course. The arteries of medium and smallest size, 
however, receive an abundant nervous supply, the nerves 
passing to the circular muscular fibres. 

" The vasomotor fibres and ganglia in the arterial walls 
receive their stimulation through non-medullated nerve 
fibres coming to them from the sympathetic nervous gan- 
glia. Phj'siological experiments have proven that these 
fibres are not derived from the sympathetic ganglia, but 
are communicating fibres from the cerebro-spinal system. 
These fibres are of two kinds, each capable of conveying a 
distinct impulse. One conveys a motor impulse to the 
vasomotor ganglia, resulting in a contraction of the arterial 
walls, while the other conveys an impulse which inhibits 
the action of the vasomotor ganglia and allows the arterial 
walls to relax. The former are known as the vaso-con- 
strictor, and the latter as the vaso-dilator, nerves. 

" Under normal conditions the vasomotor nerves maintain 
the arteries in a condition of partial contraction or tone. 
They regulate the amount of blood to a part by causing a 
contraction or dilatation of the vessels, according as the 
part requires a diminished or an increased amount of blood. 
In this action the vaso-dilator nerves are the most active. 

" The centre presiding over these nerves is in the medulla, 



68 FUNCTIONAL NERVOUS DISORDERS. 

in the floor of the fourth ventricle. This centre, in turn, 
receives stimulating and inhibitory impulses from the 
cortex. The medullary centre is reinforced by centres 
situated in the spinal cord and in the sympathetic ganglia. 

" Contraction of the arterial walls can result from but one 
cause, that being a motor impulse sent to the vasomotor 
ganglia over a vaso-constrictor nerve. Dilatation of an 
artery, however, can result from two causes, namely, a 
failure on the part of a vaso-constrictor nerve to convey its 
normal impulse, allowing the artery to become dilated by 
blood pressure, or from a vaso-dilator impulse inhibiting 
the action of the vasomotor ganglia, while the vaso-con- 
strictor impulse is present but rendered inoperative. 
Vaso-constrictor impulses are constant, while vaso-dilator 
impulses are intermittent. 

" In addition to these centrifugal constrictor and dilator 
fibres, which emerge from the spinal cord by the anterior 
or motor nerve roots, there are other fibres, entering the 
cord by the posterior roots, which convey centripetal in- 
fluences to the spinal vasomotor centres. The sensory im- 
pulses so carried to the centres provoke reflex motor action 
resulting in either contraction or dilatation of the arteries 
at the periphery. Sensory impulses, resulting in reflex 
motor action, may also reach the vasomotor reflex centres 
through the sensory nerves of the cerebro-spinal system. 

"In vasomotor neuroses either one of two conditions 
may occur. There may be a spasm of the arteries, owing 
to an excessive vaso-constrictor impulse, and resulting in 
a greater or less diminution in the blood supply to the part 
supplied by the constricted arteries; or there may be a 
relaxation of the vessels, allowing an increased blood supply 
to the parts. This arterial dilatation may be active or 
passive. In active dilatation the vaso-constrictor nerve 



VASCULAR REFLEX NEUROSES. 69 

still conducts its normal stimulus to the vasomotor ganglia, 
but its effect on the ganglia is overbalanced by the inhibi- 
tory action of the vaso-dilator nerve. In passive dilatation 
the vaso-constrictor nerve fails to convey its stimulus to 
the ganglia, either from disease of the centres or of the 
nerve itself, which allows the arteries to be dilated by blood 
pressure. This last condition is one of vaso-constrictor 
paralysis. In addition to these two conditions of spasm 
and of relaxation, there may be an alternation of excessive 
constrictor and dilator influences, resulting at one time in 
spasm and diminished blood flow, and at another in dila- 
tation and excessive blood flow. 

" Prolonged spasm of the arteries gives rise to marked 
local symptoms and is soon followed by decided nutritive 
changes. The parts supplied by the contracted arteries 
are pale, cold, and numb. The skin is shrunken and 
wrinkled. Slight tingling sensations are felt. Anaesthe- 
sia may be present to a greater or less extent. Gradually 
the nutrition of the part becomes defective, and atrophy 
with impairment of function follows. Nutrition may suf- 
fer to so great an extent as to produce ulceration or gan- 
grene. 

" The effects produced by prolonged dilatation can be di- 
vided into primary and secondary. The primary effects 
are a red or mottled appearance of the skin, associated 
with increased temperature, both subjective and objective, 
increased secretion by the part, slight hyperesthesia, and 
rapid increase in nutritive changes. These primary con- 
ditions are later followed by secondary changes, owing to 
the sluggish circulation through the widely dilated vessels. 
The hot, red surface becomes cold, blue, cedematous, and 
clammy, although the subjective heat remains. Nutrition 
suffers and function becomes impaired. In the mixed or 



70 FUNCTIONAL NERVOUS DISORDERS. 

alternating form, heat and cold follow one another in rapid 
succession. The part is alternately flushed and pallid, and 
at times bathed in profuse perspiration. 

" Turning our attention to the pelvic organs, it is seen 
that the uterus, tubes, and ovaries are richly supplied with 
nerves, both from the sympathetic and cerebro-spinal sys- 
tems, while important nerve trunks and plexuses ramify 
freely in the cellular tissue surrounding them. When we 
consider the injuries and diseases to which these important 
organs and the surrounding tissues are subject, we can 
scarcely fail to realize how seriously they must at times 
involve the nerves here distributed. As is well known, 
injury to, or irritation of, the pelvic nerve trunks and fila- 
ments is often followed by reflex disturbances in distant 
parts of the body. Irritation of pelvic nerves carrying im- 
pulses to the vasomotor centres is followed by vasomotor 
disturbances, not only in the pelvis, but also in distant 
parts as well." Dr. Smith relates the following cases which 
demonstrate how active the injuries and diseases of the 
female pelvic organs are in causing reflex vasomotor 
neuroses. 

"Case I. — Mrs. A., married, age 28, consulted me in 
1888. Previous to the birth of her first and only child, in 
1883, her health had been of the best. Labor was tedious 
and terminated by forceps. Two weeks after confinement 
she was attacked by pelvic peritonitis, confining her to bed 
for six weeks and to the house about three months. Grad- 
ually strength and health returned, and her usual light 
household duties were resumed, although she was never 
free from leucorrhoea, backache, and slight intermittent 
pelvic pain. About one year after confinement her right 
arm began to show signs of increasing weakness. There 
was a subjective feeling of coldness in the arm -and band, 
and on exposure to cold this feeling was so intensified as 



VASCULAR REFLEX NEUROSES. 71 

to become exceedingly painful. Numbness and tingling 
sensations were often present. Gradually tbese symptoms 
grew more intense, until the arm became nearly useless. 
For two years she was treated for muscular rheumatism, 
but of course with no benefit. At the time of her first 
visit to me the arm was pale and cold and the skin 
shrunken. Measurements over the middle of the biceps 
showed the arm to be one and one-fourth inches less in cir- 
cumference than the left. Weakness was so marked that 
it was impossible to raise the arm to the head and retain 
it there long enough to do up the hair. Not even a light 
weight, as a glass of water, could be safely carried in the 
right hand. The arm was habitually carried flexed at the 
elbow and drawn across the body, as if in a sling. Severe 
attacks of numbness were frequent. Repeated careful 
trials failed to detect even the slightest pulsation in the 
radial artery at the wrist. After my failures to find radial 
pulsation the patient informed me that within the past 
year two other physicians had also failed to find pulsation. 
Pulse in left radial strong and natural. Patient is positive 
that she formerly had pulsation in right radial. 

" Examination of the pelvic organs disclosed a bilateral 
laceration of cervix extending high up to cervico-vaginal 
junction. A large amount of cicatricial material was 
present. The cervix was slightly eroded. A slight chronic 
general endometrits was present. 

" Recognizing the case to be one of vasomotor neurosis of 
the spasmodic variety, and believing that it was of reflex 
origin from pelvic disease, I advised immediate treatment 
for the endometritis, to be followed, as soon as practicable, 
by repair of the lacerated cervix. This was readily con- 
sented to, and as soon as the endometritis was sufficiently 
relieved I successfully repaired the cervix. Within two 
months after the operation the arm began to show signs of 
improvement, and within six months a fairly strong pulse 
was discernible in the radial. The coldness, pallor, and 
numbness disappeared, strength fully returned, and to- 
day, two years after operation, the right arm has as great 



72 FUNCTIONAL NERVOUS DISORDERS. 

a circumference at all points as the left. No difference 
can be detected in the strength of the pulse in the two 
arms. 

" Case II.— Mrs. B., age 40, consulted me in 1887 for the 
relief of growing weakness in both legs, associated with 
numbness, tingling sensations, coldness, and pallor of the 
surface. The sensation of coldness was extremely annoy- 
ing, obliging her to sit with feet and legs near the fire 
nearly all of the time, even in warm weather. The legs 
were so weak that she required assistance in ascending or 
descending a flight of stairs, and could not, on a level sur- 
face, walk a greater distance than two short blocks. These 
troubles had been present for about two years, and had 
gradually increased in severity. She has been confined 
four times, the last being a miscarriage, at the sixth month, 
in 1882. Examination showed a single deep laceration of 
the posterior lip of the cervix, with the formation of con- 
siderable cicatricial tissue. Firm pressure in angle of 
laceration caused slight pain and tingling in legs. A 
slight cervical endometritis and erosion were present. 
Diagnosis : Vasomotor neurosis, spasmodic variety, of re- 
flex uterine origin. The endometritis was relieved by 
treatment, and the laceration then closed by operation. 

" No marked change in the condition of the legs was 
apparent for nearly six months, when improvement com- 
menced and progressed gradually to complete relief of con- 
strictor symptoms in legs within eighteen months after 
operation. The legs are now strong, enabling her to per- 
form her usual household duties, to ascend and descend 
stairs unaided, and to walk long distances without especial 
fatigue. 

"Case III. — Mrs. C, age 30, confined but once, that in 
1883, consulted me in 1888. She was suffering from 
chronic catarrhal salpingitis and chronic general endome- 
tritis. The symptoms of salpingitis and endometritis dated 
back about three years. For the past six months she had 
been greatly annoyed by rapid alternation of hot and cold 
sensations extending over the whole body, but especially 



VASCULAR REFLEX NEUROSES. 73 

marked on the abdomen, head, and shoulders. During 
the hot flushes the skin became intensely congested and 
was bathed in profuse perspiration. This condition was 
soon followed by coldness and pallor of the same parts. 
These conditions were identical with those often observed 
at the menopause. Menstruation, however, was regular, 
and is so still. 

" This was plainly a case of vasomotor neurosis of the 
mixed or alternating variety. That it was of pelvic origin 
is clearly proven by the fact that as the salpingitis and en- 
dometritis improved under treatment the vasomotor symp- 
toms disappeared. She has now been entirely free from 
these vascular disturbances for about one year." 

" The striking similarity between the neurosal symptoms 
presented in the last case and those observed at the meno- 
pause, naturally leads one to consider whether or not the 
climacteric hot flushes and their attendant conditions are 
not results of a vasomotor neurosis. I am very decidedly 
of the belief, and in that belief I hold but that of many 
others, that the hot flushes, the sudden alternations of heat 
and cold, of blush and pallor, and the local and general 
sweatings, occurring at the menopause, are the results of 
a vasomotor neurosis of the mixed or alternating variety, 
and generally of pelvic origin. That these disturbances 
are of the vascular system needs no demonstration. That 
they are of pelvic origin is shown by the report of Case 
III., where the relief of the pelvic trouble was followed by 
disappearance of vascular symptoms identical with those 
occurring at the menopause. Further, following artificial 
production of the menopause by removal of the tubes and 
ovaries, we frequently see the same vascular disturbances 
as occurred in Case III. and as occur at the menopause. 
In these cases of operation the forced cessation of function 
of the pelvic organs, and the changes which take place in 



74 FUNCTIONAL NERVOUS DISORDERS. 

the structures remaining after operation, are sufficient to 
produce the neurosis. 

" At the menopause the generative organs undergo con- 
siderable change of an atrophic nature, and their function 
is abolished. The changes in the organs are surely suffi- 
cient to set up reflex nervous derangements resulting in 
vascular disturbance. Of course it is within the realm of 
possibilities for these vascular disturbances to be of a ner- 
vous origin, independent of the changes in the pelvic 
organs; but, in my opinion, such an origin is rare as 
compared with the frequency of a pelvic origin. 

" That the vasomotor neuroses of the menopause may be 
aggravated or caused by pre-existing pelvic disease is un- 
doubtedly true. It is equally true that, as severe neu- 
roses occur at this time in women whose pelvic organs are 
not only healthy but have been all through life, they show 
that the climacteric changes are in themselves sufficient to 
produce these peculiar disturbances. I have made re- 
peated local examinations in a number of such cases, and 
failed to find any abnormal conditions of the pelvic viscera. 
It is possible that in some of these cases the vascular dis- 
turbances were occasioned by disease or derangements out- 
side of the pelvis. Careful questioning and examination 
of the patients, however, failed to show such disease or 
derangement in other parts of the body. The fact that 
these vasomotor disturbances subside after the climacteric 
changes are complete, argues very strongly in favor of a 
pelvic origin." 

On the other hand, however, there may be cases of vaso- 
motor neuroses of the menopause which are not directly of 
pelvic origin, but owe their existence to the unbalanced 
condition of the nervous system. W. J. Conklin, M.D., 
in a paper on "Some Neuroses of the Menopause," read 



VASCULAR KEFLEX NEUROSES. 75 

before the American Association of Obstetricians and 
Gynaecologists in 1889, says: "The cases are not few in 
which the neurotic affections exist independently of all 
complicating disorders of the sexual or other organs of the 
body, the peculiar nervous instability of the menopause 
being alone responsible for the symptoms. Perhaps it may 
not be amiss, in an. association where every disease is. 
viewed through gynaecological spectacles, to suggest that 
in some cases the pelvic symptoms themselves are caused 
by, not the cause of, the nervous disorders. The vicious 
circle begins in the nerve centres, not in the pelvic viscera. 
To ignore this fact and consider the latter alone is to 
wholly misinterpret the neurosis." 

The Pulse. 

In nervous and hysterical women the pulse is something 
which especially claims our attention. In very many we 
find it rapid — an increase of from twenty to forty beats 
above the normal, even in cases where the patient is not 
exercising. 

At the New York Mother Home Maternity Hospital, I 
have noted at a single visit that one patient would have a 
pulse of 52 to the minute, and in the patient beside her the 
pulse would range from 100 to 120. In neither of these 
patients would there be any form of pathological disturb- 
ance, except some slight perturbation of the nervous system 
resulting from the strain of the labor. 

Miss E. B., ;et. 20, has just recovered from a severe attack 
of chlorosis by the use of pil. Blaud cum gentian. Since 
early childhood has been subject to fainting spells ; would 
tumble over in the middle of a meal, and after being 
sprinkled with cold water would get up and finish it with 
good appetite. Lately it has been noticed that during the 



76 FUNCTIONAL NERVOUS DISORDERS. 

fainting attacks, which are always preceded by dizziness 
and an intensely sick stomach, there is, at times, redness 
(amounting to a bright flush) of the face, while in other 
attacks there is marked pallor. The extremities are " cold 
as ice." The attacks are always preceded by heart palpi- 
tation ; heart sounds are normal ; digestion is weak. 
Whenever chicken salad is taken, a fainting attack is cer- 
tain to come on after a short time. 

Vasal Weakness in the Left Side. — Mrs. M. J. P., set. 
32, weight 224 pounds, of medium height. Has been ail- 
ing for seven or eight years, but has been worse for a year 
past. Has no appetite. Distress after meals. Feels com- 
fortable only when her stomach is empty ; has " blue fits" 
and crying spells; sleepless nights or horrid dreams; suf- 
fers with numbness of the left side, and the left leg, from 
the calf down, is swollen and extremely puffy. She often 
wakes up in the middle of the night with a sensation of 
great weight and numbness in the left arm, and frequent- 
ly feels with the right hand to see if the left hand is there 
(night palsy, nocturnal hemiplegia) . Has a great deal of 
pain in the left side on walking; great flatulence of ner- 
vous origin after eating. 

This disturbance of the left side I have noted in several 
cases to be more common than on the right. It seems to 
be due to interference of the ganglia of the sympathetic of 
the left side, and also to the presence of the heart on that 
side, as decidedly a great deal of the stomach trouble occurs 
at the greater curvature ; this is the seat in almost all cases 
of the greatest amount of pain. Some patients also com- 
plain of pain over the region of the pylorus. In Mrs. P. 's 
case any surprise or shock, such as disagreeable news or 
sudden loud noise, would instantly cause an attack of purg- 
ing and vomiting, and this would even follow trivial things 
that would be unnoticed by a person in a fair condition of 
physical health. 



VASCULAR REFLEX NEUROSES. 77 

At the time she came under my notice she had been 
vomiting blood regularly for three months (vicarious men- 
struation) . She became very enthusiastic over the treat- 
ment, and said that from the first she began to improve, 
and after a few visits called herself well. 

The treatment consisted of the usual restriction of diet 
and tonic regimen. 

Vasal Weakness and CEdema Preceding Each Men- 
strual Period. — Miss M. S., set. 20, rather active temper- 
ament but not strong ; has the appearance of the scrof- 
ulous diathesis. Three or four months ago, one morning 
preceding her menstruation, the left hand was ice-cold, 
felt very heavy, and the whole arm ached. The next two 
mornings the same annoying condition returned. In the 
evening, usually about two days before the menses appear, 
the left foot and leg become much swollen, accompanied by 
warmth and a burning sensation. This remains until the 
menses appear; her face also swells at the same time so 
much as to be very noticeable. I have seen her face 
much distorted on these occasions by oedema around the 
eyes and at the base of the nose. This is a condition of 
vasal weakness or temporary functional vasal paresis, and 
is not very uncommon. Menses regular, last two days and 
a half ; extremely painful. She feels so exhausted as to 
imagine that a stroke from a feather would annihilate her. 

Angeio-neurotic oedema is one of the rare vasomotor 
neuroses. In this disorder some disturbance of the vaso- 
motor system is the principal factor in its causation, but 
the cerebro-spinal system is also implicated. It has been 
said that the cedematous swelling is due to paralysis of the 
sympathetic, but this alone is not sufficient for the swelling 
of the parts. There must be also present an active irrita- 
tion of some kind. In addition to this the lymphatics, 
veins, and arterioles are concerned in its production. It 



'78 FUNCTIONAL NERVOUS DISORDERS. 

is usually supposed to be a non -inflammatory affection lo- 
cated in the connective tissue beneath the skin or mucous 
membrane. The cedematous swelling is often quite pale, 
while in other cases it is of a dark-red color. It does not 
readily pit on pressure and is usually without pain. It 
generally comes on rather suddenly with some sensation 
of tension in the part ; its duration is indefinite, lasting 
from a few hours to several days or even weeks. 

Dr. Joseph Collins, in his extensive study of the disease, 
says that, as a rule, it does not show itself in more than two 
or three localities at a single visit, and commonly only in 
one. Sometimes its disappearance in one part is followed 
by its appearance in another at a considerable distance. 
It may appear upon the extremities, face, or abdomen; 
less frequently upon the larynx, genitals, and stomach. It 
may occur in these situations more often than is generally 
believed, on account of the difficulty of diagnosis. Its 
occurrence in any part predisposes to its return in the same 
situation. It is not so well understood, on account of its 
rarity, as are some of the more common cedemas, e.g., the 
so-called menstrual cedemas. The larynx would seem to be 
a favorite spot for its development, on account of its being 
so much exposed to the influence of a cold or a vitiated 
atmosphere. It is said to arise more commonly in parts 
which have been the seat of an injury or of an inflamma- 
tion such as erysipelas. It may be produced by a sudden 
cooling of the body such as occurs in passing from a heated 
room into the cold air without being sufficiently protected 
by extra clothing. This was noted in one of my cases, 
that of a gentleman who left a heated ball-room and rode 
a considerable distance in a cold horse-car with the extra 
protection of only a light spring overcoat. The attack in 
this case was limited to the larynx, and was of so severe 
a character that tracheotomy was required. In another 



VASCULAR EEFLEX NEUROSES. 79 

of my cases the gastro-intestinal tract seemed to be the 
seat of the irritation, which caused the affection to mani- 
fest itself reflexly in the back of the hand. There was 
excessive mental and bodily exhaustion in both these pa- 
tients, and in all my cases there was mal-digestion. The 
disease in the larynx, has been often mistaken for a syphi- 
litic manifestation in cases in which the system was per- 
fectly free from that disease. 

This reflex dermatosis has been variously termed giant 
urticaria or urticaria tuberosa, periodic swelling, acute 
idiopathic oedema, acute non-inflammatory oedema, acute 
circumscribed oedema, Australian blight, and angeio-neu- 
rotic oedema. This disease is said by some to occur more 
frequently in males than females, although other authori- 
ties state that the proportion of the sexes attacked is the 
same. It is said to be more common in cold weather and 
in parts of the body most exposed to the cold — the hands, 
face, anct larynx. Cases have been reported as having 
originated from grief and anxiety. Starr mentions a case 
of this sort. 

Dr. Collins, after an extended and critical investigation 
of this subject in The American Journal of the Medical 
Sciences for December, 1892, arrives at the following con- 
clusions : 

" 1. That there exists a variety of oedema attended by 
such striking characteristics of its own that we are justi- 
fied in referring its origin to the nervous system. 

" 2. The seat of the manifestation of the lesion is prob- 
ably in those vessels and lymphatics which pass through 
the corium to the subdermal tissues. 

"3. It is probable that although the lesions or the irri- 
tants on which the disease is dependent may attack other 
parts of the system yet the result directly appears through 
the sympathetic system 



80 FUNCTIONAL NERVOUS DISORDERS. 

"4. Evidence concerning the bearing of trophic influ- 
ences in the production of the disease cannot be produced, 
but when trophic changes do occur they are more plausibly 
attributed to the changes brought about by the oft recur- 
ring oedema, per se, than to influences exerted through 
the nervous system as true tropho-neuroses. 

"5. It is quite possible to believe that in the future its 
causation may be attributed and shown to be dependent 
upon products manufactured and ordinarily disposed of 
within the system, but which, acted on by sinister influ- 
ences either inherited or acquired, result in the temporary 
disturbance of the vasomotor system, which is manifested 
in various parts of the body, depending, as does the 
analogous condition of the distribution of blushing and 
flushing, upon structural peculiarities either central or 
peripheral, or upon inherent predilections. 

" 6. This condition has a close relationship to the many 
oedemas spoken of, and also a family relation with many 
of the arthropathies as yet not well understood, but known 
to be directly caused through the agency of the nervous 
system. 

"7. It must be admitted from clinical evidence that the 
affection in question has a family relation with other vaso- 
motor neuroses such as exophthalmic goitre and urticaria." 

It should be remembered that oedema may be produced 
artificially by the tying of a ligature tightly around the 
arm, wrist, or ankle. 

In a case of an hysterical woman who suffered from 
oedema of the hand every morning on rising, no cause 
co aid be detected by her physicians until it was discovered 
that she was in the habit of placing a tight ligature upon 
her wrist at night and removing it before their arrival in 
the morning. 



CHAPTER VI. 
PHARYNGEAL AND LARYNGEAL REFLEX NEUROSES. 

Pharyngitis and laryngitis of reflex origin are of quite 
frequent occurrence. They are often dependent upon stom- 
ach derangement. Diseased pelvic viscera are also com- 
monly recognized as the cause of their production. Irrita- 
tions of the end organs of the nerves, in either the digestive 
or reproductive organs, start up disturbances in the respi- 
ratory tract, through the intimate connection of the sym- 
pathetic nervous system and the vagus, which closely 
simulate disease of strictly local origin. 

I am quite convinced that the reflex origin of these dis- 
orders is but rarely recognized by many practitioners. 
This would seem to explain their extreme chronicity under 
long-continued local treatment of the throat. They yield 
promptly, however, to the treatment of the causative dis- 
order in the digestive or reproductive organs. The side 
of the throat or tonsil which is involved usually corre- 
sponds to the side of the abdominal or pelvic cavity where 
the disease is most intense. Less often the entire throat 
is affected. Many of these attacks precede the menstrual 
flow, and they are quite common in young girls. The 
symptoms usually complained of are soreness extending 
down the sides of the throat, and pain of an aching char- 
acter in the tonsils and pillars of the fauces. Sometimes 
the parts appear congested, at other times there are no 

local signs of disease. 

6 81 



82 FUNCTIONAL NERVOUS DISORDERS. 

Laryngeal neuroses frequently accompany menstrual 
disturbances, and stomach cough is a well-recognized 
pathological condition dependent upon chronic stomach 
disorder. It is of a spasmodic hacking character with no 
local manifestations in the larynx except a slight redness 
when the attacks are severe and frequent. Many of these 
coughs are dependent upon endometritis and dysmenor- 
rhcea. 

The most severe reflex cough I ever heard was in a 
young girl approaching puberty, and was wholly due to 
uterine disease. During the paroxysms, which were of a 
loud, dry, and barking character, the patient had to be 
held by two men to prevent her precipitating herself upon 
the floor. 

Laryngismus stridulus, a common affection in weakly 
children, is usually dependent upon gastric disorder. In 
this condition the alimentary mucous membrane should 
receive careful attention. Small doses of "gray powder" 
should first be administered, followed by large doses of 
strong tonics, such as citrate of iron and quinine. Great 
attention should be given to the diet and hygiene of the 
patient. 

Angeio-neurotic oedema is of reflex origin. It is usually 
dependent on digestive disorder, and a common location 
for it is the larynx. 

A common symptom complained of by patients suffer- 
ing from digestive disorder, is a peculiar sensation as if 
from the irritation of a hair lying upon one side of the 
phar}-nx. Others with gastric disorder have a similar 
sensation on the roof of the mouth. 

Chronic rhinitis and pharyngitis are reflex neuroses 
dependent upon imperfect digestion and excretion. The 
two are almost always present in the same patient. The 



PHARYNGEAL AND LARYNGEAL REFLEX NEUROSES. 83 

treatment which is most efficacious is brisk purgation fol- 
lowed by a proper diet and regimen. 

In a "Note on Codeine," in the Lancet, Dr. James 
Braithwaite, of Leeds, says: "Codeine seems to have a 
special action upon the nerves of the larynx ; hence it re- 
lieves a tickling cough better than any ordinary form of 
opium. One-half of a grain may be given half an hour 
before bedtime. It was in my own case that I first began 
to use codeine. For more than twenty years, usually once 
every winter, I have been seized with a spasmodic cough 
just before going to sleep, which becomes so severe that I 
am compelled to get up and sit by the fire. After an hour 
or two I return to bed and am free from the cough till the 
next winter. In other respects I enjoj" good health. 
Many years ago I found that one-half grain of codeine, 
taken about two hours before bedtime, absolutely stops the 
attack and leaves no unpleasant effect the next morning. 
In cases of vomiting from almost any cause, one-quarter- 
grain doses of codeine usually answer exceedingly well. 
In the milder forms of diarrhoea one-half to one grain of 
the drug usually answers most satisfactorily, and there 
are no unpleasant after-effects." 

Dr. C. Henri Leonard, in a paper in the Journal of the 
American Medical Association, 1892, discusses the ques- 
tion of the female voice in sexual disease, and cites numer- 
ous cases in which uterine and ovarian disease have re- 
sulted in an impairment of the voice. In one case, from a 
high mezzo the range was reduced to a contralto, and in 
other cases the masculine tones were creeping in. 

At the time of menstruation it is claimed to be a 
common occurrence for singers to find changes in the 
purity of tone or range of voice. The reason for this is 
found in the intimate connection of the nerves supplying 



84 FUNCTIONAL NERVOUS DISORDERS. 

the vocal organs (spinal accessory) and the uterus through 
the medium of the solar plexus. Taking into considera- 
tion the fact that from the lowest to the highest note the 
vocal cords vibrate from five hundred and seventy-two to 
sixteen hundred and six times a second in soprano singers, 
and that there are about a hundred muscles which must be 
brought into co-ordination to produce perfect phonation, 
it is not surprising that some slight reflex trouble will 
have the result of causing changes in the voice. 

In confirmation of his ideas Dr. Leonard cites the case 
of a patient of Dr. Severs, of Fort Wayne, who from 
reflex influences had not spoken above a whisper for two 
years. In this case cure resulted from treatment of a 
rectal trouble. 

The following case is another illustration : 

Miss S. L, aged 50, had hysterical spasm of the oesoph- 
agus, making it very difficult to swallow solid food. 
The passage of a bristle probang, which was allowed to 
remain in the throat for a short time, removed the spasm. 



CHAPTER VII. 
BRONCHIAL REFLEX NEUROSES. 

These usually take their origin in a manner similar to 
the foregoing, from lesions in the genitals, or in the diges- 
tive tract. Asthmatic attacks of great violence often de- 
pend upon nasal polypi or congestions of the mucous mem- 
brane of the posterior nares. Cases have been reported 
of nervous asthma dependent upon uterine retroflexion. 
Bronchial hystero-neuroses of pregnancy are of common 
occurrence. 

Bronchial and cardiac neuroses are often combined. 
Cheyne-Stokes' respiration has been noticed as a neurosis 
dependent upon pelvic disease. Lacerations of the cervix 
set up stomach symptoms by stimulation of the cceliac 
axis, and disordered action of the heart and difficult breath- 
ing rnay be caused by extension of the irritation along the 
pneumogastric. After the operation for lacerated cervix 
these usually disappear. Galvanism, by its action on the 
uterine nerves, sometimes permanently checks the dyspnoea 
and heart palpitation. The importance in these cases of 
carefully regulated diet and hygienic exercises cannot be 
overestimated. 

Hiccough may be termed a respiratory neurosis, as it 
consists of sudden contractions of the respiratory muscles, 
particularly the diaphragm. The starting-point of irrita- 
tion is usually in the digestive tract, although it may be in 

the uterus. Sometimes this is a very severe ailment, and 

85 



86 FUNCTIONAL NERVOUS DISORDERS. 

may produce death from loss of sleep and exhaustion. 
Among the occasional causes of hiccough are swallowing 
the saliva while smoking, or the taking of solid food im- 
mediately afterward. Renal and biliary calculi have 
been ascribed as causes of hiccough. It is quite common 
in patients who have been drinking alcoholic liquors to 
excess. 

Hiccough may be cured by holding the breath as long as 
possible, or by taking several sips of water without draw- 
ing a breath, which amounts to the same thing. If this 
should fail, a teaspoonful of ether in a little camphor water 
will often arrest it. This is, of course, when the hiccough 
is due to gastric disturbance. The cause of the disorder 
should always be ascertained and removed. 

Yawning is clearly a neurosis, but a trivial one. It is 
commonly dependent upon indigestion or pregnancy. It 
is generally supposed to be always due to drowsiness, and 
to result from a lessening of the nervous energy of the 
body. It might be deemed a very simple affair, but it is 
extremely common and rather interesting to the practi- 
tioner in that it seems to be communicable ; when in an 
assemblage one person is seen to yawn, others follow the 
action, or yawn at the same time. They seem to imitate 
each other involuntarily. Yawning is probably "catch- 
ing" upon the same principle that squint and stammering 
are, but it is not so disagreeable. It is quite possible that 
the unimpregnated uterus may be implicated in the pro- 
duction of yawning. Yawning from nervous exhaustion 
and fatigue is of centric origin; it is really a cerebro- 
spinal neurosis. 

Sneezing. — Sternutation is usually a trivial disorder, 
and is, in a manner, similar to hiccough. It is a convul- 
sive motion of the muscles of expiration resulting from 



BR0XCHIAE REFLEX NEUROSES. 87 

nasal irritation, by which the air is driven with a loud 
and hissing sound through the nasal passages. It is often 
found present as a neurosis in whooping-cough and diges- 
tive disorders, and especially when intestinal parasites are 
present, more particularly thread worms w T hich irritate the 
rectum. 

Any rectal irritation, such as that resulting from hem- 
orrhoids, constipation, or pruritus, will cause reflexly not 
only sneezing but intense irritation, with swelling of the 
tip and alse of the nose. This is particularly noted in chil- 
dren, and is a well-known sign of the presence of worms. 
Severe attacks of sneezing sometimes result from disorders 
of menstruation. There are many patients with weakened 
digestive organs who have attacks of sneezing on the 
slightest exposure of the body to cold ; in these cases there 
is often set up a vasomotor paralysis of the nasal mucous 
membrane, with a very profuse watery secretion, often 
sufficient to thoroughly soak a handkerchief in a very 
short time. Treatment for these cases is usually of a 
tonic nature — Fowler's solution, quinine, strychnine, and 
iron, with a careful rearrangement of the diet, both liquid 
and solid. The act of sneezing can be stopped immedi- 
ately by pressure with the finger across the upper lip, thus 
shutting off the blood supply to the nose and reducing the 
congestion of the mucous membrane. 

Bronchial Hystero- Neurosis of Pregnancy. — Mrs. S., 
aged 37, very stout and flabb}'. Third pregnancy. Is 
troubled with a severe cough coming on at conception, 
lasting through the whole of pregnancy and disappearing 
after delivery. This has occurred in three successive preg- 
nancies. At other times she is entirely free from bronchial 
irritation. 



88 FUNCTIONAL NERVOUS DISORDERS. 

The increased activity and growth of the uterus during 
pregnancy whenever any pathological conditions are pres- 
ent, are responsible for the frequent occurrence of neuroses, 
and these are looked upon not only by the laity but by 
the profession as evidences of impregnation. 



CHAPTER VIII. 
GASTRIC REFLEX NEUROSES. 

These are exceedingly common. All the symptoms of 
indigestion may depend upon morbid changes in other 
organs, and disappear when the causative disorder is re- 
moved by local treatment. Many cases of apparent gas- 
tritis depend upon morbid changes in the reproductive 
organs. The most common of these neuroses is the well- 
known nausea and vomiting of pregnancy, which is some- 
times so severe as to cause death. 

Among the less important neuroses of the stomach is 
the tympanitic distention, the belching and vomiting, 
which accompany menstrual congestion. Faintness, 
boulimia, and anorexia are frequently the result of uterine 
and ovarian congestion. It is said that the vomiting of 
pregnancy is simply a physiological neurosis, but I am 
convinced that the physiological changes which take place 
in the uterus daring pregnancy would not cause this reflex 
disturbance if the uterus and its adnexse were perfectly 
healthy, which among civilized women is rarely the] case. 
I have noticed that among women who have apparently 
healthy reproductive organs the vomiting in the early 
months of pregnancy is but slight and of trivial import- 
ance. Many cases of chronic gastric catarrh are asso- 
ciated with endometritis, but whether it is a reflex neuro- 
sis or not is doubtful; at any rate, the irritation set up by 

the endometritis would not be beneficial to the gastric 

89 



90 FUNCTIONAL NERVOUS DISORDERS. 

secretions. In cases where the endometritis has been re- 
lieved by curetting and other local treatment, the stomach 
symptoms have disappeared. 

In studying the gastro-hystero-neuroses we must give 
due attention to the function of the portal circulation and 
remember the morbid changes which take place from 
obstructions to its normal flow. In these cases stomachic 
remedies like pepsin, nux vomica, and bismuth are of no 
value in removing the distressing stomach symptoms until 
the pelvic disorder is relieved by appropriate treatment. 
Small fibroids and polypi of the endometrium are also pro- 
ductive of symptoms which simulate chronic gastric dis- 
ease. 

Induration of the cervix and stenosis of the cervical 
canal start up vomiting and many other forms of ner- 
vous disturbance, such as hysterical trismus, globus hyster- 
icus, and even catalepsy. Gaseous distention of the 
stomach coming on as a neurosis of the menstrual period 
may be so severe as to be accompanied by vomiting and 
pain. A very large proportion of all gynecological 
patients suffer from this neurosis. It usually comes on 
for a few days before the menstrual flow, and is sympto- 
matic of the uterine congestion which precedes the flow. 
Many of these cases are treated as attacks of indigestion, 
or as a mild form of gastritis. The epigastric region is 
usually tense, tympanitic, and sensitive to pressure. 
There is more or less backache, and with the dysmenor- 
rhcea there are usually cramps, pain in the stomach, and 
congestive headache. In some cases the epigastric swelling 
may be very marked and extremely painful. This usually 
occurs when there is sudden suppression of menstruation 
from exposure to cold or getting the feet wet. These gas- 
tro-hystero-neuroses are dependent upon pathological condi* 



GASTRIC REFLEX NEUROSES. 91 

tions of the uterus, and are often present in school girls 
who have morbid appetites, with cravings for pickles and 
chalk. These cravings are not the result of chlorosis 
alone, as is often supposed, but in many cases are depend- 
ent upon morbid irritations resulting from puberty and 
uterine catarrh. In many of these young girls a ravenous 
appetite accompanies the menstrual congestion, and is a 
result of a morbid stimulus taking its origin in a diseased 
uterus. In other patients there is complete anorexia dur- 
ing the menstrual period, and all these symptoms disap- 
pear only upon relief of the uterine disease. Quite as fre- 
quently the uterine symptoms are indications of gastric 
or hepatic disturbance, and very many cases of uterine 
catarrh and endometritis are dependent upon hepatic 
obstruction. 

A very common reflex from gastric disorder is frontal 
headache ; in fact, the great majority of headaches are re- 
flex, and a large number of them are consequent upon 
gastric or hepatic disturbance, and vice versa. Neuroses 
of the stomach are very frequent results of functional dis- 
turbance from disease in other organs. Fleisher has noted 
a diminution of the secretion of hydrochloric acid during 
menstruation, and Dr. M. Gross reports the case of a 
neurasthenic patient who was attacked after almost every 
coitus with nausea and gastralgic pains, sometimes asso- 
ciated with vomiting. The vomited matters always con- 
tained an excess of free hydrochloric acid. He also men- 
tions the fact that there is a condition of the gastric juice 
known as anachlorhydria, or nervous anacidity, found in 
neurasthenic and hysterical patients in whom no organic 
disease of the stomach is present. The great importance 
of the relations existing between the gastric juice and the 
diseases of other organs of the body must be recognized. 



92 FUNCTIONAL NERVOUS DISORDERS. 

He states that there is scarcely an internal disorder in 
which the gastric digestion is not largely implicated and 
connected more or less intimately with functional disturb- 
ances. Dr. Gross, in his article "On the Connection be- 
tween Affections of the Stomach and Diseases of Other 
Organs" (New York Medical Journal, May 4th, 1895), 
says : " A full comprehension of the morbid processes in 
the stomach, of the morbid symptoms of disturbed gastric 
digestion, cannot be obtained without considering the re- 
lations between the stomach and the diseases of the other 
organs of the body; for every affection of the stomach is 
reflected back on the other organs, and inversely every 
disease of the organs reacts upon the stomach." He speaks 
chiefly of the circulatory disturbances which lead to con- 
gestions, and their sequelae in diseases of the heart, the 
lungs, and the liver. As a matter of special importance 
he points out that in a number of cases symptoms of dys- 
pepsia precede the first signs of phthisis, and considers the 
dyspeptic troubles as the result of venous hyperemia and 
congestion coming on from the disturbed pulmonary circu- 
lation. The digestive complaints are to my mind more 
often the causative factors in the production of pulmonary 
disease than its results. 

Of the various neuroses associated with uterine disease, 
particularly retroflexion and the neuroses dependent upon 
it, the gastric neurosis is probably the most frequent. 
Often, however, we may observe the persistence of the 
gastric neurosis in spite of the cure of the retroflexion. 
Quite recently, indeed, clinical investigators have devoted 
increased attention to the digestive disturbances which 
are not due to an organic disease of the digestive appa- 
ratus, but are based upon certain conditions of irritation or 
atony of the nervous system. Every gynecologist will ad- 



GASTRIC REFLEX NEUROSES. 93: 

mit that women suffering for a long time with sexual dis- 
eases complain chiefly of associated gastric disturbances 
of a widely varying nature. In such cases we have to 
deal with dyspeptic disturbances without organic altera- 
tions of the digestive apparatus, in which the diseases of 
the uterus and its adnexa give rise to centripetal irritation 
of the nervous system, and these in a reflex way act upon 
the digestion. Thus, we often meet with gastralgias of 
the most violent kind with the onset of menstruation. In 
these cases there may be increased or continuous acid se- 
cretion, which ceases after the flow. The persistence of 
the gastric neuroses after the cure of the uterine disease is 
due (see Engelmann) to a persistence of the irritation in 
the nerve terminals. 

Gastric Neuroses of Pregnancy. — Gastric neuroses de- 
pendent upon pregnancy are exceedingly common. 

Mrs. Van H., aged 42, suffers from severe pain in the 
epigastrium, running up to the pharynx, where it mani- 
fests itself as a globus hystericus. This comes on during 
pregnancy, and is dependent upon it, and so marked is 
this relation that she says " it comes on at the very mo- 
ment of conception." She can eat only a little steak and 
very light food during the day; if she eats more she 
suffers much from nausea. She also suffers from soreness 
in the epigastric region. The tongue is perfectly clean, 
and there are no symptoms of gastric catarrh. If she 
drinks much liquid, it immediately excites vomiting. 

These conditions in her case always disappear immedi- 
ately after delivery. 

Mrs. McC, aged 58, gastro-enteric catarrh and psy- 
choses. Has always been fairly well, but has suffered 
from a sensation of fulness before having had quite enough 
to eat. Shortly after eating she eructates immense quan- 
tities of gas. Her teeth are in very poor condition. Is 
not emaciated. Is extremely nervous, and without the 



94 FUNCTIONAL NERVOUS DISORDERS. 

slightest provocation often gives way to tears. When I 
was first called to see her she was suffering from an attack 
of severe cramps and colic with extreme distention of the 
bowels. Sleep is generally undisturbed. While out walk- 
ing she worries continually about her home, and desires 
to return almost immediately. Her daughter, a young 
lady of eighteen, is also extremely nervous and suffers in a 
similar manner. In one of her attacks, after fasting a long 
time, she became delirious and was insane for some weeks. 
During this time her stomach was so weak and sensitive 
that it would not contain even a toasted cracker. The 
diet these two have been living on the past summer has 
consisted of fried meats, fruits, and watermelons. 

Hysteric Suffocation as a Gastric Reflex Neurosis. 
• — Miss Katie A., aged 30, single, has shortness of breath. 
Menses are rather scanty. At times she has pains with 
them which extend into the thighs. Slight leucorrhoea. 
During attacks of hysterical suffocation she feels like sob- 
bing. Has no cough. Lungs and heart are normal. She 
drinks four cups of coffee in the morning and two cups of 
tea during the day. This is a case of hysteric suffocation 
resulting from excessive use of coffee. 

Melancholia a Gastric Reflex Neurosis. — Mrs. S., 
aged 32. Ever since her brother's death, which occurred 
about six months ago, she has been extremely low-spirited, 
but has been complaining off and on for some years past. 
For the last two or three months suicide has always been 
in her thoughts. She is almost always in tears; her di- 
gestive organs are much disordered. She has abnormal 
appetites and cravings, and all the food which is ferment- 
able sours almost immediately after it has been taken. 
Is always very constipated. She has not left her house 
for weeks at a time. For the past two months has not been 
outside of the house, and, although physically able to do 
so, cannot be prevailed upon to take exercise. A car- 
riage was brought around to the door on several occasions, 



GASTRIC EEFLEX NEUROSES. 95 

and her husband and friends insisted on her going for a 
ride to see if it would break up the monotony and depres- 
sion from which she suffered. She immediately went to 
bed and remained there, and persistently refused to go. 
After treatment of her digestive organs her condition im- 
proved. She was induced to go shopping and on short 
visits, and finally, after careful dieting, she recovered 
completely. 

A good example of a gastric uterine reflex is to be found 
in rapid manual or instrumental dilatation of the cervix, 
which will some times start most violent reflex vomiting 
lasting for hours. I have in mind a patient who had the 
cervix dilated for the purpose of curettage of the en- 
dometrium. The result of the instrumental stretching of 
the part was to set up a violent vomiting lasting for more 
than twenty-four hours. 

The following case shows the relation between digestive 
and nervous disorders : 

Mrs. J. T. H., aged 31; nullipara, married six years. 
This patient has always had headaches, and these have 
been of one of two distinct types — one nervous and the 
other migrainous. The former is situated at the vertex, 
occurs most intensely at the menstrual epoch, but is also 
present at other times. The sensation was that of "a 
splitting pain of the head," and at times it has made her 
delirious. She also has occipital headache, and this is re- 
lieved by hot water-bags or by other forms of hot appli- 
cations to the occiput. 

The second type, or migrainous headache, has been so 
extremely severe that she has been compelled to go to bed 
as soon as the attack began. The pain is confined to a spot 
not larger than a half-dollar. Nausea comes on with or, 
as is often the case, precedes the headache. During these 
attacks a numbness starts in various parts of the extremi- 
ties, with complete loss of sensation; as the patient ex- 



96 FUNCTIONAL NERVOUS DISORDERS. 

presses it, "a cold, tingling numbness." Sensation only 
is abolished; motion is perfect. At these times she is 
much distressed by crawling sensations in the lower ex- 
tremities. I find that many other women experience simi- 
lar disagreeable sensations. 

Ever since she was a young girl she has lived in hotels, 
and has indulged in all sorts of sweets and pastries, and 
has at the present time an intense craving for candies and 
fruits. She says constipation has existed ever since she 
was born. The menstrual function is regular, but is 
scanty and painful. She has occasional attacks of anuria, 
and suffers from a pure uterine neuralgia, which is inde- 
pendent of menstruation. Her tongue is heavily coated. 
She is growing fat, and feels fairly strong. She has been 
eating everything she craves — all sorts of French cookery, 
preserves, cakes, etc. At times she has a craving for 
common potato starch and has used it by the five-pound 
box, eating it by the handful. Several of her lady friends 
have also done this. She chews a great deal of unground 
coffee. 

This case is typical of disordered conditions of the diges- 
tive organs, and secondarily of disorder of the uterine func- 
tions, the result of bad hygienic and dietetic habits. To 
correct this condition, attention must be given to the 
psychical condition of the patient. I gave this lady the 
following prescription : 

Inf. calumbee, § ss. 

Tinct. cinchonas co. , 3 ij. 

Sodii phosphat., 3 iij. 

Aq. menthse pip. , § ij. 

One teaspoonf ul in a glass of hot water, half hour before meals. 

I also carefully regulated her diet. She returned in 
about one week much improved as regards the headache, 
and her digestion was also decidedly better. 

These morbid cravings are quite common. I have seen 



GASTRIC REFLEX NEUROSES. 97 

two young girls who consumed daily one to two ounces of 
ordinary table salt. In the New York Magdalen Asylum 
it is very common for the inmates to chew tea leaves, and 
very strong coffee is frequently taken by them for its stim- 
ulant effect when they cannot obtain alcoholic beverages. 

These patients are not chlorotic, and hence these cases 
are of more than usual interest. It is evident from this 
case that there is an intimate connection between the dis- 
ordered condition of the digestive organs and that of the 
pelvic organs, and indirectly of the nervous system, as 
shown by the headaches from which she suffered. 

I am thoroughly convinced that more attention should 
be given to the digestive functions by gynecologists 
generally, and that in a large proportion of cases the 
uterine functions are of but secondary importance. 



CHAPTER IX. 
INTESTINAL REFLEX NEUROSES. 

Looseness of the bowels and flatulence are common as 
intestinal hystero-neuroses. Among young girls diarrhoea 
immediately preceding the menstrual period has been noted 
in a number of cases. There is, as a rule increased intes- 
tinal action with hypersecretion of the intestinal glands, 
following sexual connection, due to the excitement of the 
vasomotor nerves resulting from the genital stimulation. 
In others there are symptoms of vesical weakness and 
functional disturbance of the bladder. In some cases there 
is diarrhoea preceding the flow, constipation during its 
continuance, and diarrhoea for a day or two following its 
cessation, and then costiveness during the remainder of 
the intermenstrual period, and this regular succession of 
events occurs at every catamenial epoch. Vice versa, 
intestinal and rectal disease with much mucous discharge 
have a weakening effect on the sexual powers, and impo- 
tence and barrenness are often reflex neuroses dependent 
upon intestinal disease. Intestinal indigestion, constipa- 
tion, impaction of the colon and chronic diarrhoea manifest 
their presence frequently by reflex occipital headache. A 
loaded colon is a great factor in producing reflex nervous 
symptoms. When it is emptied, however, by a brisk 
cathartic, relief immediately follows, the reflex symptoms 
disappearing. Many of the dermatoses are the results of 
faecal impaction. Chloasmic spots may be the result of the 



INTESTINAL REFLEX NEUROSES. 99 

absorption of faecal material and its attempted excretion 
by the skin, or it may be a pure reflex. 

The improvement in the appearance of these patients 
under colonic flushings and hepatic stimulation is usually 
well marked. 

Scybalse, by pressure or irritation of the ganglionic 
nerves, frequently set up a severe gastralgia. 

Enteralgia or colic, the result of hysteria or severe 
mental excitement, which is probably a neuralgia of the 
mesenteric plexus, is an affection principally of the sym- 
pathetic system. 

The following case of cerebro-abdominal neurosis was 
related to me by Dr. M. Gross: 

The patient, a young woman, aged 23, was apparently 
in a fair condition of health. A few hours after witness- 
ing an accident to a friend she was attacked by a violent 
constant pain in the bowels, which exhibited marked ex- 
acerbations ; it seemed to be located in the small intestine 
as its origin in the uterus, stomach, and large intestine, 
was readily excluded. Menstruation was perfectly normal, 
the pain preceding its advent and continuing after it had 
disappeared ; the stomach was not sensitive and the loca- 
tion of the borborygmi did not involve the large intestine. 
There was no abdominal distention ; the pain was located 
in the region of the navel and gave the impression of com- 
ing entirely from the small intestine and radiating toward 
the back. She obtained slight relief only in a stooped, 
sitting posture. She had been treated by some lady phy- 
sicians with opiates in large doses, without any effect ex- 
cept to make her sleepless and miserable. 

The neurotic origin of the distress being determined, Dr. 
Gross put her upon large doses of the bromides with nearly 
immediate good result, the pain being relieved in a short 
time. 

Attacks of pain of this kind are allied to the attacks of 



100 FUNCTIONAL NERVOUS DISORDERS. 

diarrhoea and vomiting which come on from depressing 
mental excitement. Why the pain is located at this point 
and not in the uterine or cardiac nerves, is an interesting 
question ; it may be because this, at the particular time of 
the attack, was the weakest part, or the digestion may 
have been arrested at this portion of the digestive tract 
during the excitement. During digestion, there is of 
course a physiological congestion of the active part. 

Intestinal Reflex Neuroses — Nervous Diarrhoea. — 
Miss Florence M., aged 42, is of an exceedingly nervous 
temperament. Says she suffers constantly, except when 
she takes boiled milk, from a watery painless diarrhoea. 
When a child she says vegetable food of almost any de- 
scription gave her diarrhoea. Ever since, she has lived 
principally upon boiled milk. Is extremely voluble; is 
very introspective, noting the most trifling variations in 
her condition with great care, and in fact thinks about 
little else. She is a woman of good education, and when 
a young girl of twenty and for some years after was a 
writer of short stories for magazines. While engaged at 
this work the blood would leave her extremities, which 
became extremely cold, and would collect in the head and 
face. At this time the head and neck would perspire very 
freely. After completing her work she was always taken 
with diarrhoea, which became so severe that her parents 
stopped her literary work. She thought that the air of 
Chicago, her home, did not agree with her, as diarrhoea 
persisted while she remained there. At one time she 
lived from May to October on a large steamer which made 
long trips on the great lakes, and at this time she was 
comparatively free from the diarrhoea. Drugs seem never 
to have been of benefit. While I have been conversing 
with her, her face is flushed and she calls attention to the 
extreme coldness of her hands and feet. She says that she 
could outline with a pencil, and she shows with her finger, 
the areas of severe cold over the ovarian region, which 
feel "as if there were lumps of ice there." Fig. 9. 



INTESTINAL KEFLEX NEUROSES. 



101 




Fig. 9.— Intestinal Reflex Neurosis. Vasomotor Disorder. 



102 FUNCTIONAL NERVOUS DISORDERS. 

Nervous Diarrhoea. — Miss M., aged 28. When ner- 
vous from any cause, such as a severe reprimand from 
her father, or when anxious because of his intoxication, 
or the illness of her mother, who is a chronic nervous in- 
valid, she is always taken with a sudden and severe diar- 
rhoea. This condition frequently lasts for days. Bad news 
of any kind will bring on such an attack. 

Nervous Diarrhoea and Morbid Flushings.— Miss A. 
M., aged 33. Seen January 27th, 1890. During the past 
summer she has suffered from malarial symptoms, chills 
and fever, and sweatings. Had an attack about one year 
ago. Now, whenever she gets ready to go out, she has an 
attack of diarrhoea. There is no flatulence, but simply 
diarrhceal evacuations occur. Recently the attacks have 
come on the first three nights of each week. They are ac- 
companied by cramps; her face becomes excessively red, 
especially the nose, and she can scarcely see because of a 
mist which comes before her eyes. This is an evidence 
of a vasomotor flushing of the face and head. She has also 
some pain in the left ovarian region. At times there is a 
frequent desire to urinate, and both urination and diar- 
rhoea are increased at the menstrual period. She has 
monorrhagia lasting seven or eight days. These morbid 
flushings cause her considerable annoyance. 

A few days ago while she was in a hairdresser's chair, 
there was a very severe attack of morbid flushing accom- 
panied by heat and perspiration (see Plate II., Fig. 6). 
This was so noticeable that the hairdresser proceeded to 
fan her. She has had severe intestinal cramps, and be- 
lieving these to be due to a lack of the natural intestinal 
secretions and to fermentation, I prescribed Fowler's solu- 
tion, which gave complete relief. For the nervous phe- 
nomena the following simple prescription was ordered : 

]$ Potassii bromidi, 

Sodii bromidi, aa § ss. 

Syrupi, § iv. 

Sig. One teaspoonful every three hours. 

The effect of the bromides was to stop the menorrhagia, 



INTESTINAL REFLEX NEUROSES. 103 

and her menstruation now lasts only four days. For the 
malarial complications which were thought to be possibly 
a powerful causative factor, five grains of quinine were 
given three times a day. This, she says, acted as a brisk 
cathartic. This result I have noted before in other 
patients of a nervous type. 

The preceding case is one of morbid flushing; in fact, it 
was for this that she principally consulted me, although 
the nervous diarrhoea was also quite troublesome. 

The following, by Dr. John Hilton, is a good example of 
transferred symptoms. The irritation from an anal ulcer 
is transferred probably through the medium of the spinal 
cord or through the sympathetic to other organs in the ad- 
jacent parts. 

Case of Anal Ulcer Producing Retention of Urine 
and Symptoms of Pregnancy. — "The case is that of a 
young lady, aged about 22, whom I saw some years ago 
with the late Dr. Golding Bird. She was an excellent 
dancer, good company in a drawing-room, and thought to 
be a very agreeable and attractive person. Gradually 
she receded from that position in society, lying down 
a good deal on the sofa, suffering much pain, always un- 
comfortable, occasionally quitting the room, whether in 
society or at home among her own relations. It was 
noticed that she had occasional sickness, menstruation was 
not regular, the abdomen was decidedly increasing in size. 
She became very fond of lying in bed instead of going to 
balls and dances — in fact, she said she could not dance or 
enjoy society at all — and was very uncomfortable. A. 
surgeon was consulted, who, perceiving the patient's 
changed character, and finding the lower part of the 
abdomen decidedly large and prominent, mentioned a 
suspicion of pregnancy to her mother. Her mother, 
who was personally acquainted with the late Dr. Golding^ 
Bird, took her to him. He examined her carefully. 



104 FUNCTIONAL NERVOUS DISORDERS. 

and said: "She is not in the family way, depend upon 
it; I think the symptoms arise from piles, or something 
wrong in the rectum." It was under these circumstan- 
ces that I was requested to examine her. I found her 
suffering from piles and prolapsed rectum, retention of 
urine nearly complete, enlarged abdomen, sickness, loss of 
appetite, constant pain at the lower part of the stomach, 
bowels constipated, frequent loss of blood from the rectum, 
and extreme pain during and after defecation. Her ill- 
ness commenced, many weeks before I saw her, with great 
pain in passing a motion, and all her urgent symptoms 
resulted from the original anal ulcer. This was the order 
of events: The nerves of the anus and neck of bladder 
being derived from the same trunk nerve — the pudic — the 
nerve irritation extended from the anal ulcer to the mus- 
cles of the neck of the bladder and urethra. This caused 
them to contract, and produced difficulty in making water, 
and subsequently the retention of urine. The protracted 
distention of the bladder caused pressure upon the rectum, 
interfering with the return of blood from near the anus, 
and this, added to the straining of the patient to relieve 
herself, caused distention of the rectal veins and partial 
prolapse of the rectum. Hence arose all the other symp- 
toms to which I have adverted. 

" I passed a probe between the projecting folds of the 
rectum, and soon made out where the ulceration existed. 
I removed a portion of an external pile, and then obtained 
a clear view of it, situated just within the anus, full half 
an inch wide, and more than three-quarters of an inch in 
length; muscular fibre formed its base. I divided the 
sphincter muscle through the centre of the ulcerations, and 
nearly the whole of the painful symptoms quickly sub- 
sided, and the patient was soon well and as happy and 
gay as ever. I have seen the lady several times since, and 
she has remained perfectly well." 

Miss H., aged 30, has an enlarged retroverted uterus 
with much tenderness and prolapse when evacuating the 
bowels and at menstrual periods. The pain was so severe 



INTESTINAL REFLEX NEUROSES. 105 

that Alexander's operation of shortening the round liga- 
ments was proposed by a well-known New York gynecolo- 
gist. This condition was accompanied by a severe form 
of chronic indigestion, and the patient was extremely 
anaemic and worried. She went to the country for the 
summer, and returned in the fall in perfect health, not 
having taken in the mean time any medicine or submitted 
to any operation. This case exemplifies the fact that 
many cases of uterine disease are dependent on, or aggra- 
vated by, the disturbance of the digestive organs. This is 
undoubtedly true of dysmenorrhcea. If we succeed in 
strengthening the patient and curing the indigestion, the 
pains at menstruation disappear. 



CHAPTER X. 
THE RENAL REFLEX NEUROSES. 

Cases of marked variations in the secretion of urine 
may be reflex or symptomatic. Psychological changes are 
great factors in modifying the secretion of the kidneys, the 
emotions affecting the renal secretions even more strongly 
than they do those of the bowels. The urine secreted under 
the influence of nervous excitement is copious and limpid. 
Sudden changes of temperature by reflex stimulation 
cause marked renal irritability and increased micturition. 
The hypersecretion of any gland is simply the result of in- 
creased nerve stimulation, and mental excitement follow- 
ing stimulation of the emotions is a common cause, not 
only in man but in animals, of an increase in the secre- 
tion of urine. 

Neuralgic pains are not so common in the kidneys as in 
other organs of the body, but when they do occur they 
are sometimes very severe and of an aching character.. 
Anything which tends to enfeeble the vital powers pro- 
duces a marked modification of the urinary flow. In very 
many of these cases of renal functional disorder there is a 
large amount of urea excreted, and the urine is of a very 
high specific gravity. In patients with nervous prostra- 
tion the urine is often very pale in color. In the cases in 
which there is an excess of urea discharged there is also a 
tendency to the deposit of oxalate-of-lime crystals. These 

may be present in great numbers and of large size. The}r 

106 



THE EEXAL EEFLEX NEUROSES. 107 

are evidence of debility, and indicate morbid nervous in- 
fluences. The increased secretion of the watery elements 
of the urine following upon an hysterical attack is a com- 
mon occurrence in the practice of all physicians. 

The Duchess of C. is a very corpulent, neurotic patient, 
all of whose family were consumptive. She possesses the 
peculiarly thin, silky hair which accompanies that state, 
and is of a marked scrofulous diathesis. Although an 
elderly woman, she has a remarkably delicate pink and 
white complexion. She suffers a great deal from nervous 
dyspepsia accompanied by frequent gaseous eructations. 
She has had attacks of pseudo-angina pectoris. Her men- 
tal condition exercises a most remarkable influence over 
the renal secretion. While suffering from nervous excite- 
ment lasting two days and following an accident to her 
carriage, she urinated about every ten minutes during 
that time, and passed a very large quantity of pale urine. 
She claims that while riding either in a carriage or in the 
cars anuria exists; she never feels the slightest desire to 
urinate even though the journey should last for two or 
three days, although when at home she urinates fre- 
quently. While in attendance at the deathbed of her 
daughter she had an attack of polyuria and claims to have 
passed within a few hours more than three gallons. This 
statement, however, may be taken cam grano salts, as 
a great many of these patients have a tendency to " elabo- 
rate," and possibly she exaggerated a little. But there is 
no doubt that she passed a very considerable quantity. 

(Some of the recent authors have called attention to the 
fact that the granular kidney is frequently of nervous 
origin. See Medical Record, November 24th, 1894.) 



CHAPTER XI. 
THE VESICAL REFLEX NEUROSES. 

These are common in women, but the literature is not 
Very extensive. The most common cause is some diges- 
tive, uterine, or rectal disease affecting the bladder reflexly 
through the sympathetic. Lesions of the cervix are com- 
mon sources of irritation, as are thread-worms, anal fis- 
sure, hemorrhoids, constipation, sudden change of tem- 
perature, mental disturbances, and the irritations of the 
female urethra from too acid urine, the result of bad 
digestion or a urethral caruncle. 

No one has written more lucidly on this subject than 
Dr. Alexander J. C. Skene. 

Among the functional disturbances of the bladder are 
frequent urination, painful urination, incontinence of 
urine, difficult urination, pain after urination, and reten- 
tion of urine. Emotional disturbances are prominent fac- 
tors in functional derangements of the bladder; fear and 
fright are among the most common of these which influ- 
ence discharge. Frequent urination, and the sudden evac- 
uation of the urine with modifications of its character, are 
common results from disturbances of the nervous system. 
In nervous and hysterical conditions the urine may be 
limpid, acid, and very excessive (polyuria). "Nervous re- 
tention of urine (ischuria) is also very common. Difficult 
and painful urination are likewise conditions frequently 

met with as neuroses. Incontinence of urine in children 

108 



THE VESICAL REFLEX NEUROSES. 109 

is often dependent upon digestive disorder, and disappears 
immediately on its correction. Many derangements of 
the bladder are said to result from malaria. This can be 
explained, not only by the malarial poison affecting the 
bladder and urethra through the nervous system, but 
probably by a mechanical agency at work in addition to 
the nervous cause of the disease. 

The congestion of the liver which is present in malaria 
interferes with the portal circulation and thus causes a 
congestion of the bladder. Removal of the hepatic ob- 
struction causes a ready disappearance of the disorder. 
It is claimed that the much-maligned ovaries are respon- 
sible for many of the neurotic disturbances of the bladder. 
Ovarian irritation is undoubtedly a frequent factor in the 
production of excessive urination and also of scanty urina- 
tion and dysuria. A feeling of pressure and uneasiness 
is often present; the pain in the bladder is usually con- 
fined to the neck, and is generally most severe during 
the act of micturition. In these cases a careful examina- 
tion of the urine fails to find any deviation from the nor- 
mal standard. The bladder itself is not sensitive, and the 
condition is readily determined to be a pure neurosis de- 
pendent upon the inflammation and disturbance in the 
ovary. Treatment directed to the inflamed ovary usually 
causes a disappearance of the bladder symptoms. It is 
difficult to differentiate between renal and vesical neuroses 
on account of the intimate connection of the parts. 

In the treatment of the reflex neuroses of the bladder 
tonics should be administered and a careful regimen en- 
joined. Among the drugs found useful are mix vomica, 
iron, quinine, and the vegetable bitters. The digestive 
organs should receive special attention, and the slightest 
deviation from their normal condition should be at once 



110 FUNCTIONAL NERVOUS DISORDERS. 

corrected. The diet should be simple and nourishing, and 
all indigestible articles carefully excluded. Pleasant com- 
pany should be sought after, especially at meal-times, and 
cheerfulness should be cultivated. Strong tea and coffee, 
wines, condiments, and all other articles which are inhibi- 
tory of digestion should be strictly avoided. Diluents and 
soothing decoctions should be given by the mouth. The 
mild alkalo-saline waters, such as Highland water, and 
preparations of uva ursi, triticum repens, scoparium, and 
acacia are useful for removing irritation. Local applica- 
tions of laudanum, belladonna, chloral, and morphine 
may be used with advantage either as suppositories or in- 
jections per rectum. Bladder injections containing a 
small quantity of morphine are also useful in removing the 
sensitiveness of the mucous membrane. 

Enuresis is a common and troublesome affection of 
childhood, often difficult to manage. It is most common 
in nervous children suffering with digestive disorders. 
It is undoubtedly in many cases a neurosis resulting from 
reflex irritation. The various causes of this disorder are 
obscure. The most valuable remedies are those which are 
tonic in their action, such as iron and strychnine. Tinc- 
ture of belladonna is recommended in five-drop doses. 

The whole subject of reflex bladder troubles is a vexed 
question, and these disorders are often difficult of diagno- 
sis. A most thorough investigation to discover the cause 
of the trouble should be made before any course of treat- 
ment is attempted. 

My friend, Dr. R., gives me the details of the following 
case: 

Mrs. H. had been married for about four months, and 
the marriage had never been properly consummated owing 



THE VESICAL REFLEX NEUROSES. Ill 

to the fact that the approach of her husband had always 
resulted in a sudden and uncontrollable emptying of her 
bladder, a real incontinence of urine. It had never oc- 
curred before she was married, and never at any other 
time than on attempting to perform the marital act. No 
matter how often or how infrequently the attempts were 
made, the result was always the same. The consequence 
was that the husband was thoroughly disgusted and unable 
to accomplish the act. Strychnine, belladonna, and can- 
nabis indica were tried without any benefit. Cauteriza- 
tion of the neck of the bladder, however, was followed by 
marked improvement. 



CHAPTER XII. 
THE REFLEX GENITAL OR HYSTERO-NEUROSES. 

Many of the hystero-neuroses are very severe in their 
manifestation. They most commonly occur at the men- 
strual period. Genito-urinary disturbances are reflected 
to any part of the body, but more frequently to the hypo- 
gastrium, the vertex, and the occiput. Pains are also fre- 
quent in the lumbar region, knees, ankles, and wrists; also 
in the neck below the occiput. The terminals of the cere- 
brospinal nerves are frequently implicated. 

When hystero-neuroses are constant, they are usually 
increased in severity by menstruation, or by anything 
which causes uterine congestion, such as colds or over- 
exertion. Sometimes, however, the menstrual discharge 
decreases their severity. The pains in the small of the 
back follow the distribution of the nerves around to the 
hypogastric region, and the pain is usually more marked 
on the diseased side. It is sometimes localized between 
the shoulder-blades. I had a patient in whom the pains 
of labor were all reflected to the head. She was also a 
victim of hystero-epilepsy. Another patient had them all 
in the thighs — this latter is a rather common condition. 

The pains of the hypogastric neuroses are superficial, 
and are diffused along the terminal nerves; while the 
pain from local inflammatory conditions is deep-seated, 
and due to direct mechanical pressure. 

The pain in the occiput and back of the neck is com- 

112 



THE HYSTERO-NEUROSES. 113 

monly described by the patient as being " like two drawn 
cords in the nape of the neck." 

In the vertex the pain is commonly of a pressing or 
burning character, and an eruption or dermatosis some- 
times results. 

A very common hystero-neurosis is the quiverings and 
shakings in the abdomen, of which a large number of 
patients complain. 

Superficial pains in the toes, soles of the feet, and heels 
are often said to result from ovarian and uterine, as well 
as from gastric disease. They usually occur on the same 
side as that of the affected tube or ovary, and in gastric 
disease, if the left side be painful, then the greater cur- 
vature of the stomach is the probable seat of the inflamma- 
tion. If the toes and fingers of the right side are affected, 
then without doubt a duodenitis is the cause, the irritation 
being at the pyloric orifice of the stomach. This is due 
probably to the distribution of the sympathetic nervous 
system. 

Coccygodynia is sometimes a hystero-neurosis. 

Narcolepsy, Trance, Lethargy, Hallucinations, Ante- 
cedent to the Establishment of the Menstrual Function 
{a Hystero- Neurosis) . — Edna S., aged 12, still in short 
dresses, is in good condition physically ; suffers with head- 
ache, mostly frontal, more frequent in the afternoon ; is a 
thoughtful, energetic, bright, cheerful child, with an ex- 
ceedingly acute memory. She has the face of a girl of 
sixteen. Appetite good; bowels regular; is not ansemic, 
and has a plentiful supply of fresh air. Her mother died 
of phthisis when the child was five years old; her father 
is very frail and delicate. On returning from school, for 
some time past, she has always been dizzy and drowsy and 
wishes to go to bed immediately, instead of, as heretofore, 
playing with her dolls and enjoying herself. After a 



114 FUNCTIONAL NERVOUS DISORDERS. 

quarrel or an attack of fretting, she has hysterical hallu- 
cinations of vision, every object seeming of double size. 
Every object that comes in contact with her body, such as 
a sheet, seems to be extremely heavy. When in a nervous 
state after crying, she has the feeling that the lips, tongue, 
and hands are swollen to a great size, although no swelling 
is visible. She usually retires between 8 and 9 p.m. In 
the morning when awakened and called to get up, she 
hears but cannot move; her mind is awake but she has no 
power of motion ; her eyelids are closed and she has to be 
vigorously shaken every morning. She is not lazy or tired, 
but she cannot move a muscle when in this state. She 
will hear commands and orders, but is unable to obey 
them, and lies like a log. If left alone, she will remain in 
this condition for from twelve to fifteen hours. At times 
there is a sensation of constriction, as of a band around 
the head. 

Her father has suffered from attacks of trance. He 
has lain in a cataleptoid state, heard and knew his friends 
by their voices, but has been unable to move — mind 
awake, but body asleep. 

When sensation is returning, in the case of the child, a 
peculiar prickling, as of needles, is felt in an increased de- 
gree. After coming out of an attack she often has to slap 
her hands to aid the return of sensation. 

Under treatment by tonics and a nutritious diet this 
patient has very much improved. 

I wish to refer here to a pathological condition which I 
have observed, and which has not yet (to my knowledge) 
been noted save by a very few medical authors. I refer 
to recurrent sexual orgasms in women. In the following 
cases they existed as a reflex from ovarian irritation : 

Mrs. S., aged 22, veryansemic; has had two children, no 
miscarriages; last pregnancy four months ago; did not 
nurse the baby, and it died from marasmus. Has been 
weak and nervous for the last five years. Has had within 



THE HYSTER0-XEUR0SES. 115 

a short time four attacks of sexual orgasm, with consider- 
able discharge. Bowels constipated. Has pain in the left 
ovarian region. 

Miss C. H., aged 27, pale, large, strongly built. Has an 
orgasm three or four times some days. Uterus tender on 
examination. Has a burning sensation in left ovarian 
region. 

Mrs. A. R., aged 36, widow. Married twelve years; 
widow for nine years; three children. Menses first at 14; 
they recur every two or three weeks, duration five to 
eight days, flow profuse. Has some aching pain twenty- 
four hours before the flow and continuing through the first 
day. Leucorrhcea, slight but continuous. With the bear- 
ing-down pains has an orgasm. Does not masturbate or 
have connection ; very sensitive about the internal genitals. 
Urinates every fifteen or twenty minutes. Bowels regular. 
Has lacerated cervix. 

Rosenthal, of Vienna, says: 

" I had under my care a young hysterical female who 
performed peculiar suction movements during her parox- 
ysms, during sleep, and in a condition of semi-conscious- 
ness. One day, as her consciousness was returning, I dis- 
covered a mucous fluid upon the external genitals, al- 
though the genital organs were normal. After having 
often observed a similar occurrence, I decided to warn the 
patient that she was concealing secrets from me which 
would undoubtedly result to her detriment. She then con- 
fessed that she secretly read light novels at night, that she 
then had erotic dreams, and, that upon waking, she felt 
exhausted and worn out. The hysterical paroxysms de- 
veloped after this condition of excitement had lasted 
several months. A trip to the country and hydrothera- 
peutic measures caused the disappearance of the pollutions, 
and the hysterical seizures yielded soon afterward. In 
another case, a patient, during profound sleep, saw her 



116 FUNCTIONAL NERVOUS DISORDERS. 

dead mother appear before her, and begged her pardon for 
concealing the fact that she had a mucous discharge from 
the genitals after voluptuous dreams, blaming the obscene 
books loaned by a friend as the cause of the discharge 
and of the hysterical paroxysms. This flux, caused by 
erotic excitement of the nervous system, is produced by the 
glands of Bartholin and by the acinous glands surround- 
ing the meatus urinarius." 

As a rule these involuntary orgasms occur at night and 
result from masturbation, erotic thoughts, and over-ex- 
citement of the genital organs by stimulating food and 
drinks, diseases of the rectum, hemorrhoids, habitual 
constipation, and worms; diseases of the bladder, inflam- 
mation and calculi, irritation of the urethra and glans 
clitoridis. These orgasms weaken the nervous system and 
lower the vital energies, thus affecting nutrition. When 
long continued they cause melancholia and mental weak- 
ness. 

In the treatment of these conditions, as in that of all the 
reflex neuroses, we should endeavor to remove the cause. 
When they are due to constipation or hemorrhoids, these 
should be relieved by attention to the liver and digestive 
tract. If worms are present, we should give injections of 
the cold-water infusions of quassia, or very weak solutions 
of carbolic acid, corrosive sublimate or vinegar, the latter 
being preferable on account of its less poisonous action. 
It is also very important when these parasites are present 
to abstain for a time from the use of sweets and fresh milk, 
and to add much salt to the diet. 

These patients should sleep on a hard mattress, lying 
upon the side and with merely a light covering. The dorsal 
decubitus tends to stimulation of the genital organs. 

Among the drugs which may be administered are qui- 



THE HYSTER0-NEUR0SES. 11? 

nine and iron for their tonic effect, and Fowler's solution, 
belladonna, camphor, lupulin, and bromide of potassium. 
From these good results may be expected. Great benefit 
is also derived from cold sponging of the body. Electric- 
ity is also useful, but its application, should not be too 
severe or prolonged. 



CHAPTER XIII. 
THE GLANDULAR REFLEX NEUROSES. 

Probably the most important glands which we have to 
consider in this connection are the breasts. All irrita- 
tions in the pelvic organs manifest themselves to a greater 
or less degree by changes in the mammary glands. The 
most common reflexes are swelling, engorgement, and 
pain. These glands are intimately connected with the 
other sexual organs, and the functional activity of both is 
absolutely interdependent as they are but different parts of 
one apparatus — the sexual. 

Sensations of tenderness in the mamma are not infre- 
quent manifestations in young women at their menstrual 
periods, and at the beginning of pregnancy. Again, at 
the period of the " climacteric " sensations of similar nat- 
ure may occur and they may accompany various diseased 
conditions of the pelvic organs. The subjects usually 
affected are women of a highly sensitive disposition or 
those with hysterical tendencies. The tenderness may be 
very slight, or there may be actual and severe pain. 
Sometimes so excessive is the tenderness that the slight- 
est touch cannot be endured. When this is the case it is. 
termed mastodynia. Many patients afflicted with mas- 
todynia are thoroughly convinced that they are suffering 
from cancer or some other serious ailment. Tonic treat- 
ment, with local sedatives and dietetic regulation, are 

often the only remedial measures necessary. 

118 



THE GLANDULAR KEFLEX NEUROSES. 119 

Uterine or ovarian pain resulting from inflammation is 
frequently accompanied by a reflex pain in the breast, and 
disturbances of the uterine condition, either by menstrua- 
tion or conception, are usually followed by congestion 
of the mammary glands. In some cases of dysmenor- 
rhcea the breasts become exceedingly tense and painful. 
The pain is of a lancinating character, penetrating to the 
shoulder blades, and is present during the entire menstrual 
period, but disappears upon the cessation of the flow. In 
other cases the shooting pains in the breast and the sore- 
ness of the nipples precede the appearance of the menstrual 
discharge, and pass away entirely with its disappearance. 

Changes in the other glands, accompanying pathological 
conditions of the digestive organs, are much more common 
than is generally supposed and have not to any very great 
extent been brought to the attention of the medical pro- 
fession. 

Thyroid enlargement is often a well-known reflex, de- 
pending upon activity of the genital organs in the female. 
This was well known by the ancients, who considered en- 
largement of the neck as an evidence of consummation of 
marriage or of the occurrence of pregnancy. It was cus- 
tomary to measure the neck with a fillet before and after 
the first night of the married state. I am inclined to 
think that the globus hystericus is nothing more nor less 
than a neurosis dependent upon the physiological conges- 
tion of the thyroid. 

Hypersecretion of the salivary glands is frequently 
known to accompany menstruation, and is one of the first 
signs of pregnancy. It is sometimes very severe and 
annoying in the early months, and does not entirely pass 
away until delivery. There is an intimate connection be- 
tween the parotid glands and the reproductive organs. 



120 FUNCTIONAL NERVOUS DISORDERS. 

Cases have been reported where a diseased ovary has 
caused reflexly the suppression of the secretion of the 
parotid gland on the same side. Parotiditis sometimes 
causes a painful oophoritis. This is undoubtedly due to 
sympathetic transference, such as takes place in the testes 
of the male. Severe inflammation of the parotid has taken 
place in cases of ovariotomy. Several instances of this 
kind have been reported by Drs. Emmet, Mann, Reamy, 
and others. 

Hepatic neuroses are frequently dependent upon emo- 
tional disturbances. This fact is well known to non-medi- 
cal writers, for the novelists speak of the sallow counte- 
nance presented by the hero or villain after he has passed 
a sleepless night, torn by conflicting emotions. The emo- 
tional jaundice is here probably the result of disturbances 
of the vasomotor system. 

Many of the glandular neuroses have been considered 
under other headings, such as intestinal, renal, etc. 

Excessive perspiration of the hands and feet, as a reflex 
symptom from digestive disorder, is very common. The 
feet in these patients, being encased in shoes which pre- 
vent evaporation, often present the white and wrinkled 
appearance seen when the skin has been soaked for a long 
period in a strong solution of soda. 

Many persons with weakened digestive organs and con- 
stipation have a strong odor in the urine, due to intestinal 
decomposition of sulphur compounds and the pronounced 
appearance of indican in the excretion. It is probably the 
same decomposition that produces the malodorous perspi- 
ration in the axilla, and which is often much more exces- 
sive on the right side. Its greater frequency there is 
probably due to the presence of the liver and the empty- 
ing of the portal s} T stem on that side. In some of these 



THE GLANDULAR KEFLEX NEUROSES. 121 

subjects the left axilla may be entirely free from odor. 
This odor is of a much stronger kind- in the negro race, 
and also in people with very pronounced red hair. Some 
young women of the latter type suffer much from this 
pecularit}". In the ball-room, when they become heated 
from dancing and are perspiring profusely, it requires the 
whole effect of the very powerful and pungent perfumes 
which they use to disguise this disagreeable odor. 

Hyperhidrosis — Ephidrosis. — The following case lately 
came under my notice, but circumstances prevented me 
from making more than a superficial examination : 

Mr. H., a young man, a blond, 25 years of age, much 
addicted to the use of alcohol, exhibits a curious phase 
of this condition. On the warmest days, and after vio- 
lent exercise, he will exhibit no signs of perspiration on 
his head, face, or neck, but from the second joints to the 
extremities of the fingers of each hand a copious perspira- 
tion will be present. So profuse is it that he can by shak- 
ing his hand sprinkle the perspiration around in large 
drops. This peculiar condition may be the result of some 
morbid process in the liver, such as diabetes. 

The glandular organs of the body are markedly influ- 
enced by the vasomotor irritations arising in the sympa- 
thetic. The glycogenic function of the liver and excretion 
by the kidneys are under the control of the sympathetic. 

The cervical sympathetic, as well as its distribution in 
the thorax may, when irritated and disturbed, cause uni- 
lateral hypersecretion of sweat. Cases have been reported 
of unilateral hyperhidrosis the result of Basedow's disease 
or diabetes. Here there is myosis on the affected side, 
redness of the skin, and elevation of temperature. In one 
of these cases galvanization of the cervical sympathetic 
caused profuse sweating upon the corresponding part of 
the face and head, while in another case a result exactly 



122 FUNCTIONAL NERVOUS DISORDERS. 

opposite was obtained. Fraenkel, in his Inaugural Dis- 
sertation, Breslau, 1874, reports the case of a patient 
with cardiac and thyroid hypertrophy, accompanied by 
attacks of dyspnoea and hyperhidrosis of the left half of 
the face. On autopsy the left cervical sympathetic was 
found covered with rounded nodules as large as grains of 
sand, blackish -brown in color. On microscopic examina- 
tion they were found to consist of varicose vascular dila- 
tations with a formation of fusiform cells in their walls, 
The ganglion cells were strongly pigmented and filled with 
dark cells. 

Seguin, in the American Journal of the Medical Sci- 
ences, October, 1872, reported a case of a male patient, aged 
fifty years, who came under his notice. This man had 
exhibited for a number of years a unilateral hyperhidrosis 
in which, while the left side was profusely bathed in per- 
spiration, the right remained entirely dry. The patient 
died of exhaustion, and the autopsy revealed large cancer- 
ous masses in the abdominal cavity affecting principally 
the mesenteric glands. Another deposit of carcinomatous 
tissue as large as a small orange was found behind the 
left clavicle, external to the sterno-mastoid muscle. On 
the right side the cervical sympathetic was found to be 
adherent to the sheaths of the pneumogastric nerve and 
the vessels. The superior ganglion and adjacent parts 
were much injected. 

These conditions are certainly of much interest. In some 
cases mechanical compression of the sympathetic nerve 
is readily determined, while in others the condition is 
quite probably of reflex origin, from disturbance in the 
thoracic, abdominal, or pelvic cavities. 

Hemidrosis — Unilateral Hyperhidrosis. — This is not 
a very unusual condition. In two cases which recently 



THE GLANDULAK KEFLEX NEUROSES. 



123 



came under my observation the left side was affected. 
One was a lady of about thirty, of strong frame, but suf- 
fering at this time from a severe chronic bronchitis, worse 
on the left side. The explanation of the hemidrosis in this 
case would seem to be that the ganglia of the sympathetic 
in the region of the left lung were excited, and the fibres 




Fig. 10. —Hemidrosis. 



also of the sympathetic controlling the secretion of sweat 
were stimulated by a local sepsis ; or, the pressure of the 
enlarged bronchial glands caused the stimulation, and took 
this means (unilateral sweating) of ridding the body of 
the poison. Half of the face, head, and body were bathed 
in a profuse perspiration, the hair on that side being very 



124 FUNCTIONAL NERVOUS DISORDERS. 

wet, while the opposite side of the face, head, and body 
was perfectly dry. In the other case the cause of the func- 
tional aberration was not determined, the patient being 
apparently in robust health. She passed from my observa- 
tion before the obscure cause of the disorder could be 
ascertained. 

The pathology of this symptom is obscure. It is well 
known that severance of the sympathetic in horses causes 
a profuse unilateral perspiration. 

A case is reported of paroxysms of angina pectoris with 
■hyperhidrosis of the left side. On post-mortem examina- 
tion the ganglia of the left sympathetic showed a patho- 
logical condition of the blood-vessels, which were dilated 
and varicose, while the nerve tissue on the right side was 
perfectly normal. In this case, Ebstein claimed that the 
hyperhidrosis resulted from a temporary or permanent 
compression of the nerve elements of the sympathetic with 
resulting paralysis. Rockwell reports a case which indi- 
cates an involvement of the vasomotor and oculo-pupillary 
fibres of the sympathetic. 

Patient, a male, set. 65, was extremely feeble, and 
suffering from digestive disorders. There was profuse 
unilateral hyperhidrosis involving the right side of the 
body, and the right leg and foot to a less extent, while the 
left side was at all times abnormally dry, the median line, 
both front and back, sharply defining the two conditions. 
There was persistent congestion of the conjunctivae. The 
right ear was redder and hotter than the left. There was 
considerable myosis, suggestive of paralysis of the oculo- 
pupillary as well as sympathetic vasomotor fibres. The 
hyperhidrosis lessened under the galvanic and faradic 
currents. 

Localized perspiration is much more common than 



THE GLANDULAR REFLEX NEUROSES. 125 

general perspiration. In some cases it is confined to the 
hands and feet alone; in others the axillse, sca]p, and peri- 
neum are the only parts affected. I have at present under 
my observation a brother and sister, both of whom sweat 
excessively from the hands and feet. In the case of the 
young man, who is about eighteen, the feet are the most 
affected. They are constantly soaked with perspiration, 
and have the peculiar wrinkled appearance presented by 
the hands of a washerwoman who has been all day engaged 
at her avocation. In these two cases, as with most patients 
suffering from this disorder, both diet and hygiene are 
improper. A strong solution of chromic acid, as a local 
application, was of benefit to both of these patients. 

Hartmann mentions the case of a woman who during 
pregnancy perspired only from the right side of the body, 
and Sir Erasmus Wilson speaks of a young lady under his 
care whose hands drip with perspiration, the palms filling 
with the secretion, under the influence of a slight ner- 
vous excitement. He also mentions the case of a man with 
severe gastric disorder who called on him one morning 
with " rills" of perspiration running down one side of his 
face and forehead, the other side being perfectly dry. 

An eminent actor told him the following anecdote of 
himself. When a young man he had one night been 
playing in a tragedy in which he had become violently 
heated, and had scarcely had time to cool when he had 
been obliged to go on the stage again in a character which 
required that he should make up as an old man of eighty. 
In the course of the play he had been struck by the great 
amount of attention of which he was the recipient, especial- 
ly from those in the audience who were nearest to the stage. 
Concluding that it was the excellence of his acting which 
was attracting such attention, he felt flattered and exerted 



126 FUNCTIONAL NERVOUS DISORDERS. 

himself to the utmost. He was thoroughly puzzled, how- 
ever, at the sensation which he seemed to be creating, and 
at the bursts of laughter in the wrong places which greeted 
him. Upon retiring to his dressing-room he found that it 
was not alone the excellence of his acting which had so 
excited his audience, but the droll appearance of his face, 
one-half of which had been washed clear of its painted 
wrinkles by a partial perspiration and displayed the youth- 
ful features of a young man of twenty, while the other half 
exhibited the careworn lines and wrinkles of eighty. 

On his chest the perspiratory side was reversed, the 
side corresponding to the perspiring side of the face being 
perfectly dry, and the other side bathed in a profuse sweat. 
At a later period the perspiratory action ceased over the 
entire body. 

Cutaneous hemidrosis may be considered as a neurosis 
referable to the cutaneous system. I prefer not to class it 
as a dermatosis. 

Bromidrosis. — My friend, Dr. Peter Murray, has given 
me the particulars of the following case of bromidrosis : 

Miss G., aged 18 years, suffered for a considerable time 
with excessive and most fetid perspiration of the feet, and 
so copious was the secretion that as she walked across the 
floor a "swashing" sound was heard at every step, her 
shoes being literally full of water. The special point of 
interest is the immediate success of the treatment insti- 
tuted. The feet were bathed in hot water, and afterward 
liberally powdered with a mixture of equal parts of sali- 
cylic acid and borax. This caused considerable irritation 
for two days. Extract of witch-hazel was also used after 
the hot water with the result of completely curing the dis- 
order. The patient was seen a year afterward, and had 
had no relapse. 

Dr. Murray also mentioned the case of a gentleman 



THE GLANDULAR EEFLEX NEUROSES. 127 

with whom he is acquainted who claims never to have 
perspired. Upon the hottest days his face gets intensely 
red and shiny, and appears as if about to burst, but re- 
mains perfectly dry. The patient's age is sixty-five, and 
he is of a thin, spare habit. 

I remember some years since having seen a lady of 
about fifty years who suffered in a precisely similar man- 
ner, never perspiring even in the hottest weather or after 
severe muscular exertion; she had some eczema of the 
upper extremities, and was almost bald. The suppression 
of the sweat secretion was productive of considerable ex- 
haustion and much distress. 

A saturated solution of bichromate of potash, applied 
twice a day, is said to be a sure cure for bromidrosis. It 
was of advantage in all the cases in which I have used it. 
In the German army dilute chromic acid is said to be 
almost exclusively employed for excessive sweating of the 
feet. 

I have also prescribed chromic acid with much success 
for patients who suffer from this disorder and who engage 
in avocations requiring the handling of polished steel in- 
struments. On account of its acid character the perspira- 
tion is most destructive to the polish on such instruments. 



CHAPTER XIV. 
THE OPHTHALMIC REFLEX NEUROSES. 

Many ophthalmic symptoms are dependent not only 
upon ovarian and uterine affections but are common 
manifestations of digestive disorder. They are indepen- 
dent of any structural change in the eye. Among the 
more common reflex neuroses of the eye are : asthenopia, 
amblyopia, hysterical amaurosis, menstrual amaurosis, 
gravidarum amaurosis, retinal hyperesthesia, retinal 
anaesthesia, photophobia, dimness of vision, mouches 
volantes, disturbances of accommodation, hysterical stra- 
bismus, hemeralopia (night blindness), nj^ctalopia (day 
blindness), mydriasis, and myosis. 

It is not at all uncommon for patients afflicted with 
chronic abdominal and pelvic disease to be troubled with 
asthenopia and dimness of vision, yet in the mind of the 
average practitioner the interdependence or reflex charac - 
ter of these conditions is by no means well established. 
Cases of transitory amaurosis or amblyopia resulting regu- 
larly from a menstrual reflex, have been reported, and 
these have disappeared completely under uterine treat- 
ment. In some cases the ophthalmic symptoms are cere- 
bral neuroses or psychoses, being of hysterical origin. In 
many patients undoubtedly the weakness of the eyes is 
dependent upon the general systemic weakness arising 
from chronic digestive disorder, and a good course of tonic, 

dietetic, and hygienic treatment would invigorate the sys- 

128 



THE OPHTHALMIC KEFLEX NEUROSES. 129 

tern sufficiently to cause them to disappear; yet in some 
instances they are true reflex neuroses. In a patient under 
my care there is not only impairment of vision but there 
is a limitation of the visual field. If she endeavors to 
read, or gazes steadily at any fixed object for a time, dark, 
wavy lines seem to intervene. There is no structural dis- 
ease of the eye present; the patient is' neurasthenic, and 
suffers from chronic gastric catarrh, cardiac weakness, 
and incipient renal disease. 

Disturbances of vision are quite common as menstrual 
neuroses where pelvic inflammation is present, the greater 
involvement being in that eye corresponding to the side 
where the inflammation is the more intense. 

Retinal hyperesthesia and anaesthesia are not only cere- 
bral neuroses but are common results of pelvic inflamma- 
tion. They also result from indigestion following the use 
of coarse vegetable food. Ptosis may result from the irri- 
tation reflected from hepatic and gastric disease. Lacera- 
tion of the cervix is responsible for some of the reflex 
ophthalmic neuroses. It is claimed that photophobia may 
also result as a reflex from endometritis and cellulitis. 

Puerperal amaurosis resulting from eclampsia might be 
classed as a cerebral neurosis depending, as it probably 
does, on uremic poisoning of the cerebral centres. This 
functional disorder must not be confounded with retinitis 
albuminurica, from which it is entirely distinct. 

Asthenopia is sometimes a cerebral neurosis dependent 
on a lack of mental energy; the patient has lost confi- 
dence in his power of using his eyes. Psychological 
treatment is here, of course, indicated. 

Many cases are on record of hysterical amblyopia and 

amaurosis and a great variety of means have been adopted 

for the sudden cure of these cerebral neuroses. Persons 
9 



130 FUNCTIONAL NERVOUS DISORDERS. 

with weak eyes should not read, write, or do any fine 
sewing on an empty stomach. A neurasthenic patient of 
mine who suffered greatly from a blurring of vision and 
the appearance of wavy lines in the atmosphere was 
always vastly relieved for a time by partaking of a full 
meal. Under careful treatment directed to the digestive 
organs, this reflex neurosis entirely disappeared. 

In mydriasis the dilatation of the pupil is usually con- 
fined to one eye, and the vision is much disturbed. 
Sometimes it is of organic origin, as a result of certain 
forms of brain disease, such as hydrocephalus, apoplexy 
at the base, concussion, etc. It is frequently intermit- 
tent, especially when caused by entozoa. It often sub- 
sides spontaneously or upon removal of the causative 
disease. 

The condition of myosis may result from irritation of 
the oculomotor nerve, which in turn may depend upon 
obstinate constipation or spinal paralysis. It is often an 
obscure affection. 

Photophobia is in some cases a violent ophthalmic re- 
flex resulting from uterine disease. Haziness and dim- 
ness of vision are frequently present at the same time. In 
cases of chronic cellulitis mouches volantes are supposed 
by very many physicians to be reflex neuroses dependent 
on renal disease, but they are also frequently present in 
cases of endometritis and pelvic cellulitis. 

The oculo-pupillary disorders arising from compression 
of the cervical or upper portions of the dorsal cord gener- 
ally appear as a paralytic myosis, and a spasmodic mydri- 
asis. These symptoms may alternate. In some cases both 
eyes are affected ; in others only one. 

The cervical sympathetic is very rarely the seat of trau- 
matic lesions, and hitherto but few cases have been re- 



THE OPHTHALMIC KEFLEX NEUROSES. 131 

ported. During the American Civil War, Mitchell, More- 
house, and Keen had under observation a soldier who 
had been shot behind the lower jaw on the right side, at 
the anterior border of the sterno-mastoid muscle. The 
bullet made its exit on the left side, below and about an 
inch from the angle of the lower jaw. The wound healed 
in six weeks. When examined in the tenth week there 
was marked myosis (especially when the eye was shaded) 
of the right pupil. There were also myopia, slight ptosis, 
conjunctival redness, and frontal pains on the same side. 
Several times an unusual redness of the left side of the 
face was seen after exertion. While in a state of repose 
the temperature was found normal in the mouth and both 
ears. The foregoing symptoms are similar to those which 
are observed as resulting after experimental section of the 
sympathetic in animals. 

Kaempf (Ges. d. Wien. Aerzte, March 8th, 1872) re- 
ported the case of a soldier who was wounded in the cervical 
region, and presented right paralytic myosis from injury 
to the right sympathetic. Galvanization was frequently 
tried without any result. When the cervical region of 
the cord or the brachial plexus is wounded disturbances 
in the cervical sympathetic may also arise. Hutchinson 
has observed unilateral myosis, narrowing of the palpe- 
bral fissure, and elevation of the temperature on the corre- 
sponding side of the head. In addition to this, Seelig- 
muller (Berliner klinische Wochenschrift, 1870 and 
1872) reports a case with emaciation and atrophy of the 
cheek on the same side as the injury. Rosenthal also re- 
ports a case of injury to the cervical cord with persistent 
slowness of the pulse and very marked dilatation of the 
left pupil. 

Observations upon fractures of the cervical vertebrae 



132 FUNCTIONAL NERVOUS DISORDERS. 

have been published by Rendu, in which other symptoms 
of irritation accompanied the unilateral mydriasis. In 
luxations of the vertebrse, however, myosis was observed, 
with symptoms of paralysis, as was also found by Rosen- 
thal to be the case in two patients suffering from caries of 
the odontoid process. In certain forms of ataxia, and in 
progressive muscular atrophy, a considerable amount of 
contraction of the pupil on the affected side is generally 
observed. Periodical attacks of sciatica are liable to 
occur in these cases, often with hyperesthesia of the skin. 
During these attacks spasmodic mydriasis sometimes ap- 
pears upon the side affected. Here I desire to mention the 
great satisfaction with which I have read the volume en- 
titled "Uterus and Eye, a Treatise upon the Functions 
and Diseases of the Female Sexual Organs in their Patho- 
genic Influence on the Organ of Vision," by Dr. Salo 
Cohn. This work gives the whole subject in systematical 
classification, and is so much more to be appreciated as it 
pays close attention to a domain that has up to the present 
time never been thoroughly cleared. It is therefore at 
once theoretically interesting and practically important 
not only to the ophthalmologist and gynecologist but also 
to the general practitioner, who may learn to cure func- 
tional diseases of the eye by treatment of the genital 
organs. This work again shows how important it is that 
even in devoting ourselves to one special we ought to 
remain in close connection with general medicine. The 
author has also classified the normal and pathological 
functions of the female sexual organs and has on a physi- 
ological base shown the way upon which the pathogenic 
influence reaches the brain and eye. 

The conditions of puberty and the climacteric which are 
not at all clear in the minds of the ordinary practitioner 



THE OPHTHALMIC REFLEX NEUROSES. 133 

have received a thorough elucidation and are classified 
with regard to their pathological features into the chapters 
on menstrual anomalies. When looking over this work 
we are surprised to see how intensely normal menstrua- 
tion as well as pregnancy and parturition may influence 
all parts of the visual apparatus from the lids up to its 
centres. The puerperium and lactation play also an im- 
portant role in producing affections of the eye of some- 
times a grave character. Finally, the question how loss of 
blood affects the organ of vision has received exhaustive 
attention. The whole work, that brings two distant parts 
of the body in close connection, a connection which is 
formed by the nervous system, verifies to a great extent 
the theories and facts that I have laid down in this book, 
which is in a measure a supplement to the before-men- 
tioned work and proves by many cases the truth of his 
premises. Like the author mentioned I also distinguish 
between the general morbid condition of the body that 
may pathologically interfere with the normal functions of 
an organ and the pathological condition of a part of the 
body that may cause disturbances in a distant organ. The 
author gives precisely his standpoint referring to the gen- 
eral distinction between reflex and hysteric action of a 
nerve. He thinks that such a distinction does not exist 
at all and that we have to deal with only one kind of irri- 
tation. 

This reflex action we recognize as such if we find out its 
origin, but are we permitted to call the irritation hysteric 
because we do not find the cause? We know very well that 
sometimes the original affection, as the author mentions, 
may have disappeared. The original wound may have 
healed, but the nervous irritation, sensible or insensible to 
the patient, may persist and continue, for a time at least, 



134 FUNCTIOtfAKtfERVOUS DISORDERS. 

to produce its evil effects upon the distant part of the 
body. I may add, according to my experience, that this is 
the cause for so many disorders, especially in the female, 
that are generally and falsely classified as hysterical dis- 
orders. The electric current may still influence the bell 
through the medium of the wire even after we have re- 
moved the pressure from the button. This shows again 
that we are approaching the time when the word hysteria 
will perhaps be entirely stricken out of medical termi- 
nology. In every case where we find a trace that leads us 
to a morbid point, we have certainly not the right to 
speak of hysterical irritations. In all these cases we have 
to use the term reflex; at the present time we have to 
limit at least the term hysteria to those conditions where 
mental emotions apparently play the prominent part with- 
out any other visible or, to our imperfect methods, detect- 
able cause. The acceptance of this statement by the profes- 
sion will tend to still further clear up an obscure part in the 
disturbances of the nervous system. If we are aware that 
the so-called hysteric condition is sometimes a grave affec- 
tion we shall in the first instance try to find out the causa- 
tive point, and even if we do not succeed we have no right 
to shrug our shoulders at such an unhappy patient and 
declare all her suffering as pure and simple imagination. 
"The evil is," as Dr. Cohn in his work correctly remarks, 
" by no means imaginary but really exists, and the patients 
generally suffer severely under caprices of their ailment 
which they try in vain to master by 'an energetic will.' " 
I am fully convinced that I am not the only one who on 
the occasion of a post-mortem found out the pathologic 
origin of the death of a patient who for many a year was 
treated for hysteria, and I remember a case belonging to 
this group where even a large aneurism of the abdominal 



THE OPHTHALMIC KEFLEX NEUROSES. 135 

aorta escaped the examining eyes of the physicians as 
cause for the symptoms that went to make the diagnosis 
"hysteria." 

It is interesting also that some affections of the eye have 
been called hysterical. Those that come under observa- 
tion in connection with the functions of the female genital 
organs or in connection with dysmenorrhceic troubles, 
according to Dr. Cohn, do not form a separate category, 
but belong rather to that group of cases in which a func- 
tional disturbance of the eye is induced by reflex action 
from a local genital affection. Can we, for instance, con- 
sider the contraction of the visual field as a support for the 
diagnosis of hysteria, if we hear from the author men- 
tioned that this same contraction is brought about by the 
menstrual process and is found in a series of other disor- 
ders? Are we justified in treating patients with " hysteric" 
symptoms in a careless and contemptuous manner, if we 
read in the same book that after long duration of such an 
" hysterical" affection of the eye, where the fundus at first 
did not present any perceptible change, hyperaemia of the 
papilla may set in at a time when there is no attack, and 
lastly may bring on organic alterations in the optic nerve? 

Functional Mydriasis. — Miss E.,-aged 25, a neuras- 
thenic, is considerably annoyed by intermittent mydriasis 
of the right eye, the pupil undergoing excessive dilata- 
tion, while the iris in the left eye remains in a state of 
inaction. This is caused hj a spasmodic action of the 
dilator pupillae, resulting from irritation of the sympa- 
thetic or the cerebro-spinal nerves communicating with it. 
It is of an ephemeral character, and may be a reflex from 
either nasal disorder or some irritation in the abdominal 
or pelvic cavity. It may be of the nature of chorea. 
Many persons, in a nervous or slightly weakened state, 
have a certain amount of twitching of the upper lid, due 



136 FUNCTIONAL NERVOUS DISORDERS. 

to reflex irritation. Helminthiasis is often represented as 
a cause of ephemeral mydriasis. 

In Miss E.'s case weakness of the digestive organs is 
probably the foundation of the disorder. Eggs in any 
form always bring on a severe attack of indigestion, ac- 
companied by a migrainous headache. The application of 
strong solutions of nitrate of silver to the post-nasal region 
was followed by a marked improvement in the digestive 
symptom. Disagreeable disturbances of accommodation 
frequently occur as reflexes in neurasthenic, dyspeptic 
persons. 



CHAPTER XV. 

THE AURAL REFLEX NEUROSES. 

The aural reflex neuroses are probably not of great im- 
portance, still they are of sufficient moment to be given a 
place. The following are good examples : 

Aural Reflex Neuroses ivith Vasomotor Disorder. — 
Mrs. McN., aged 68. This patient's stomach has always 
been weak, and she now has marked anaemia from chronic 
gastro- intestinal catarrh. For the last three months she 
has had a burning neuralgia on the vertex, which radiates 
all over the head. Accompanying this are whistlings and 
noises in the ear which are extremely annoying. For the 
last two days the sensation has been like the snapping of 
parlor matches. She starts up in the night talking in her 
sleep. She is costive and the appetite is extreme!}' poor. 
Some slight improvement occurred under dietetic treat- 
ment. 

Aural Reflex Neuroses, Vasomotor Disturbance; 
Anaemic Roaring. — Miss S., aged 29, suffers every day 
from a roaring noise in the head which is so loud that she 
imagines that people sitting in the same room can hear it. 
She is very anaemic, and it takes but little to make her 
faint. She is exceedingly pale except over the malar 
prominences, and suffers from a very severe menorrhagia 
which is so profuse as to often cause faintness. She has 
pain on locomotion, and there is also pain in the back and 
in the left side. The roaring in her head ceases when her 
head is lowered, and she generally sleeps without a pillow, 
but her sleep is restless. She has an excellent appetite. 
There is severe leucorrhoea. On examination, I find the 

137 



138 FUNCTIONAL NERVOUS DISORDERS. 

neck of the uterus is occluded by a large mucous polypus. 
This was removed, and the patient gradually recovered 
her health. 

Unilateral Ancemic Roaring. — Mrs. C. H. C. , aged 
39, is far advanced in phthisis. She is excessively anae- 
mic; her expectoration is viscid and exceedingly copi- 
ous. She experiences the most distress from an intermit- 
tent sensation of loud roaring in the right ear and the 
whole of the right side of the head. She complains more 
of this and is more anxious for its relief than for that of 
any other symptom. It is quite evident to my mind that 
the inflammatory disorder of the left lung is the source of 
this trouble and that the irritation is transmitted through 
the decussation of nerve fibres in the spinal column (de- 
cussatio pyramidum) to the right side of the head in the 
floor of the fourth ventricle. The auditory nerve, through 
which in this case the irritation is manifested, takes its 
origin in the floor of the fourth ventricle. Pathology here 
demonstrates what microscopical anatomy teaches. Care- 
ful examination of the ear showed no local disorder 
present. 

Under a superficial examination of this case the practi- 
tioner would be apt to consider it a purely local disorder, 
and direct his treatment to the ear, giving no attention 
whatever to the chest and abdominal cavity, which should 
always be interrogated when obscure aural symptoms are 
present. 

A common reflex from the auditory nerve is the sensa- 
tion which is popularly known as " setting the teeth on 
edge," and arises from harsh and scratching noises; the 
effect being generally more pronounced on the person who 
causes the sounds, perhaps on account of the irritation 
being transmitted in a measure also through the spinal 
column. These sensations are intensified in those who are 
ansemic and sensitive. 



THE AURAL REFLEX NEUROSES. 139' 

In some cases of ansemia, from insufficient or improper 
diet, along with mental worry, the patients suffer attacks, 
of a peculiar nature. Immediately following a slight sen- 
sation of fear or depression there is a hyperesthesia of all 
the special senses. If the patient is walking in the 
streets, the sound of her own and others' footsteps is most 
distressing ; people seem to rush by her with great vio- 
lence, or, if they remain behind, she fears they are about 
to pounce upon her ; their movements seem to be distress- 
ingly energetic and extremely rapid. If riding in a horse- 
car or other vehicle, the sensation of a very rapid and dan- 
gerous pace is experienced when the horses are merely 
going at a slow trot. It is all hallucination, but reasoning 
and knowledge of its incorrectness do not remove it. The 
tongue also is in a state of extreme sensitiveness. Distant 
and insignificant sounds are fancied to be in the immedi- 
ate vicinity of the patient, and of deafening volume; and 
even the vision seems to be somewhat sharpened. These 
manifestations are unaccompanied by any sensation of 
pain. 



CHAPTER XVI. 

LINGUAL REFLEX NEUROSES. 

Cases of lingual neuralgia, without any objective signs 
of inflammatory action being present in the tongue, are 
often very severe and obstinate. Of the reflex and neural- 
gic character of this disorder there can be no doubt. 
Local applications, as a rule, afford no relief. It is some- 
times remarkably persistent, lasting in some cases for 
years. It is more common in women than in men. One of 
my patients who has suffered with this disorder never ex- 
perienced an attack unless -she visited a certain fashionable 
watering-place, when within twenty-four hours an attack 
always came on with great severity. Her teeth are good 
and well cared for, and there is no sign of local disease of 
the tongue. It is natural in color and normal in size, 
without any indentation of its edges. The tongue is 
peculiarly susceptible to nervous influences of either an 
organic or functional character. This is seen in the uni- 
lateral coating occurring in cases of hemiplegia resulting 
from cerebral hemorrhage, while the stammering in cases 
of mental fatigue is probably due in a degree to a lack of 
nervous strength in the organ. The neuralgia is most 
common in neurasthenic and melancholic patients with 
imperfect digestion. Some women suffer from it only 
during pregnancy. In some cases the patients experience 
great difficulty in articulation, and the taking of any food 
except in a liquid form is impossible, owing to the severe 

pain experienced. 

140 



LIXGUAL KEELEX XEUR0SES. Ill 

Burning sensations in the tongue are not uncommon re- 
flex sensations in women. They are often of hysterical 
origin, and care must be taken to differentiate them from 
similar sensations accompanying inflammatory conditions. 
In the superficial forms of glossitis the tongue is dry, 
glazed, exceedingly red and tender with an accompanying 
burning sensation. When the inflammation is deeply 
seated there is often much swelling. 

In the treatment, a tonic regimen should be carried out, 
and Fowler's solution in five-drop doses given three times 
daily combined with quinine five grains. Iodide of potas- 
sium may also be given in small doses. In some cases Dono- 
van's solution may be of value, or pills of the carbonate of 
iron and gentian, freshly made. Blaud's pills, as ordinarily 
sold in the drug stores, like the quinine pills, are often so 
insoluble that they are of little use. 

Dr. John Hilton, in his work on "Rest and Pain," men- 
tions the following cases, which are interesting in this con- 
nection : 

Furred Tongue on One Side, Depending on Disease 
ivithin the Cranium. — " The first time I had an oppor- 
tunity of clearing up such a case as this occurred in 1843. 
On December 17th, 1843, 1 examined, with Mr. Blenkarne, 
a surgeon in the city, the body of one of his patients, who 
had died with disease of the brain and spine. She had 
suffered from intense pain on the left side of the head. 
She had also, during her life, a tongue furred on the left, 
and scarcely at all on the right side. It became, therefore, 
an important point to clear up what was the probable cause 
of that condition of the tongue. We made a post-mortem 
examination and found, as was anticipated, a diseased 
spine. Then, upon very careful examination of the head, 
on turning up the dura mater from the anterior part of 
the petrous portion of the left temporal bone, for the especial 



142 



FUNCTIONAL NERVOUS DISORDERS. 



purpose, we exposed the Gasserian ganglion, or the gang- 
lion of the fifth nerve. We there found what might be 
called a scrofulous deposit upon the convex edge of this 
ganglion, involving the second division, of the fifth nerve 
more than the third, but still involving all more or less. 
Here, then, appeared to us to be the probable explanation 
of the tongue furred on its left side. This observation 
was made in 1843; the disease was near the ganglion of 
the fifth nerve, and on the same side as the furred tongue. 
If I should not mention the fact again, it will be clearly 




Fig. 11.— Sketch of a tongue furred only on the left side, resulting from a de- 
cayed and painful second molar tooth in the upper jaw of the same side of 
the head. 



understood that the diseased condition of the tooth, or of 
the fifth nerve, was always found on the same side as the 
furred tongue, and that the fur was confined to the an- 
terior two-thirds of the upper surface of the tongue, over 
the distribution of the lingual gustatory nerve — a portion 
of the third division of the fifth." 

Furred Tongue on One Side Caused by a Decayed 
Tooth on the Same Side.— " The sketch (Fig. 11) is of a 
tongue furred on one side, and comparatively clean on the 
other. This furred condition of the tongue is frequently 
associated with a diseased condition of the second and 
third divisions of the fifth nerve. It is, in fact, a func- 
tional and structural deterioration depending upon ner- 
vous influence. 



LINGUAL REFLEX LEUKOSES. 143 

" Recently, a lady, whom I have known for some years, 
consulted me regarding some matters not of importance, 
and I, perhaps not for any very precise purpose, said, 'Let 
me look at your tongue. ' She put out her tongue, and it 
was furred on one side. I said, 'You have a bad tooth,' 
and she thought it was exceedingly clever on my part. 
'Yes,' she replied, 'and I am going to Mr. Bell to have 
it taken out. ' She went and had it extracted ; I saw her 
a fortnight afterward, and all the fur had subsided. 
This was a second molar tooth in the upper jaw of the 
same side as the furred tongue." 

I have also seen the side of the tongue coated from tip 
to base from toothache, while the centre and other side 
were quite normal in color. 
10 



CHAPTER XVII. 

THE ARTICULAR REFLEX NEUROSES. 

Pain in the hip, knee, ankle, shoulder, elbow, and wrist 
is often a transferred pain or of reflex origin.* Many cases 
of hysterical joint are undoubtedly true neuroses, but they 
are very puzzling symptoms, and require careful investiga- 
tion and treatment of both the digestive and reproductive 
organs before they become manageable. Pain in the knee 
is commonly associated with uterine disease. An anky- 
losis of the knee-joint, or a lameness, may be either a 
psychosis or a gastric or uterine reflex. A laceration of 
the cervix, accompanied by a local inflammation upon one 
side of the uterus, has been known to produce pain and 
stiffness in the knee of the same side. Pain and tender- 
ness at the hip-joint, simulating hip disease, may result 
from uterine disorder, thus showing its reflex nature. 
Pains in the wrist and ankle have been spoken of as of 
ovarian origin. They usually exist upon the same side 
as the affected ovary- 



* A most learned clergyman, whom I am treating, tells me that 
when a youth at the "hobbledehoy" age he was exceedingly shy, 
and whenever called upon to present himself prominently to the 
gaze of others, he was immediately seized with an intense weakness 
in the knees. This was so severe on one occasion as to cause him 
to fall flat upon the floor. He was also the victim of morbid blush- 
ing. 

14-4 



THE ARTICULAR REFLEX NEUROSES. 145 

Stiffness of the joints of the lower extremities has been 
noted as an accompaniment of menstruation in cases of 
pelvic inflammation, coming on shortly before the cata- 
menial flow, increasing with its height and disappearing 
with its cessation. 

Dr. John Hilton gives the following explanation of 
hysterical pain in hip or knee joint : 

" The sacral ganglia and the lower lumbar ganglia of the 
sympathetic nerve are connected with the great sciatic 
nerve, and partly also with the obturator nerve. These 
same ganglia are connected likewise with the nerves pro- 
ceeding through the broad ligament to the uterus and to 
the ovaries. I think we have here, then, an explanation 
of the frequent occurrence of what we call hysterical hip- 
joint or hysterical knee-joint. If the nerves in the ovaries 
or the uterus be in a state of irritation, that irritation can 
be conducted to these sacral nerves or to the obturator, and 
then, in accordance with the generally received law of 
distribution of nervous influence, irritation or pain may be 
manifested at the other peripheral or articular end of the 
same nerve. Hence it may be expressed within the knee- 
joint, on the inner side of the knee-joint, or it may be 
within the hip-joint, because the hip-joint as well as that 
of the knee receives its nerves from these various sources. 
The posterior part of the hip-joint, you will remember, has 
nerves coming to it from the sacral plexus. The sacral 
plexus receives some filaments from the sacral ganglia ; so 
do the uterine and ovarian nerves ; and it is quite possible, 
nay, I think is very likely, that the irritation commenc- 
ing in the ovaries or the uterus might be conveyed to some 
of the filaments derived from the same ganglia in the 
sacrum, and irritation in the hip-joint be thus produced. 

You will observe that the two nerves, which are so dis- 
10 



146 FUNCTIONAL NERVOUS DISORDERS. 

tributed as to be capable of producing the pain in the 
joints, are the great sciatic and the obturator; and I be- 
lieve this is a probable explanation of the fact that of all 
the joints in the human body affected hysterically as we 




Fi3. 12.— a, Spinal cord. 6, Spinal nerves going to the posterior part of the body- 
behind the vertebral column, c, A visceral artery accompanied by branches of 
the sympathetic nerve, d, Common spinal nerve, composed of motor and 
sensory filaments, e, Portion of intestine (uterus or ovary) receiving minute 
filaments from the spinal nerves and sympathetic nerve. /, Ganglia of sympa- 
thetic nerve, united to each other by longitudinal filaments, and receiving 
branches from, as well as giving off branches to, a common spinal, motor, 
and sensory nerve. 

The arrows indicate the directions which any intestinal, uterine, or ovarian 
irritation might pursue centrifugally, either directly backward to the skin in 
that region, or along a spinal nerve to its muscular, articular, or cutaneous 
destination. 

term it, none are so frequently involved as those of the 
hip and the knee. Sir J. Paget, to whose lot it has fallen 
to see more of these cases than to any other surgeon, save 
perhaps the late Sir B. Brodie, speaks as follows in his 
* Clinical Lectures and Essays,' edited by Howard Marsh, 
p. 197 : ' Among all the joints, the hip and the knee, 
which are the most frequent seats of real disease, are 



THE ARTICULAR REFLEX NEUROSES. 147 

equally so of the mimicry — a fact not easy to account for. 
It may be due to mental association, perhaps unconsciously, 
or to a mingled inheritance — for instance, to an inheri- 
tance of nervous constitution and of relative weakness in 
the joint or joints most weak in progenitors.' By tracing 
these two nerves, I think we may find a probable interpre- 
tation of that frequency. I have here constructed a dia- 
gram intended to represent what I have been alluding to. 
Suppose this (/) to represent the three ganglia of the sym- 
pathetic ; we have then a spinal nerve (d) attached to the 
spinal cord, and taking its onward course to the muscles 
and the skin. We know that these spinal nerves commu- 
nicate with the ganglia, and so, by the sympathetic 
branches travelling along the arteries (c) , reach the intes- 
tine (e), uterus, and ovaries. Let us assume, then, that a 
patient may have irritation from any cause in the intes- 
tine, in the uterus or ovaries, or in the broad ligaments. 
On this map we may trace the course of that intestinal, 
uterine, or ovarian irritation through the ganglia, through 
the spinal nerve and spinal marrow, thence to be reflected 
to any part of the peripheral or articular distribution of 
that same spinal nerve. This condition, I apprehend, is 
sometimes very clearly recognized in the case of the in- 
testines. Who is there that has not felt griping pains in 
the interior of the intestines from some morbid agent lying 
there, or from drastic purgatives traversing the gut, ac- 
companied by pains or cramps in the leg, and pains in the 
loins? — conveyed in the latter instance by the filaments of 
spinal nerves, which pass to the posterior part of the body 
or the lumbar region. And is it not a common occurrence 
in cases of uterine and ovarian irritations for the patients 
to complain of pain in the joints, but particularly over the 
posterior part of the sacrum? The ovarian and uterine 



148 FUNCTIONAL NERVOUS DISORDERS. 

nerves traverse the ganglia of the sympathetic, and so 
reach the spinal nerves. Hence the morbid influence con- 
veyed by the posterior branches of the spinal nerves to the 
skin over the lumbar and sacral regions explains the lum- 
bar and sacral pains experienced by such patients." 



CHAPTER XVIII. 
THE DERMAL REFLEX NEUROSES OR DERMATOSES. 

A very definite relation exists between the skin and the 
internal organs. In cases where a derangement of the 
stomach, liver, kidney, or uterus coexists with a skin dis- 
ease, the removal of the internal disorder frequently causes 
the disappearance of the cutaneous affection. This results 
from the intimate functional interdependence of the vari- 
ous parts. In the treatment of all skin disorders special 
attention should be given to what physiology teaches — 
that is, the intimate connection between the functions of 
the skin, liver, and kidneys. " Imperfect digestion and in- 
efficient renal elimination are the causes of one-half of all 
skin diseases, and this is particularly noted in gouty and 
rheumatic subjects. 

The connection between dermatoses of the face (such as 
acne and chronic redness) and uterine and digestive de- 
rangements is noted by all practitioners. 

Many of the dermatoses are merely symptoms of general 
diseases whose chief seat is the internal organs. Such 
affections are said to be often the results of faecal impac- 
tion. 

Among the reflex neuroses of the skin are : 

1st. Hyperesthesia. 

2d. Anaesthesia. 

3d. Perverted sensibility. 

Under the heading of neurotic disease of the skin may 

149 



150 FUNCTIONAL NERVOUS DISORDERS. 

be classed pruritus, prurigo, urticaria, herpes, acne ro- 
sacea, lichen. 

Pruritus as a reflex neurosis is frequently dependent 
upon gastro-intestinal and genito-urinary disturbances. 
Rich, stimulating, and indigestible diet, intestinal para- 
sites, and many digestive and uterine derangements are 
among the common causes of this disorder. The itching 
may be general or local ; in digestive disorders it is usu- 
ally the extremities which are most affected, although the 
entire surface of the body may be involved. Among the 
varieties of its local manifestations are: Pruritus ani, 
pruritus vulvae, pruritus urethrse, pruritus nasi. 

Prurigo as a reflex dermatosis is common in advanced 
life. The itching is of a peculiar, burning, tingling char- 
acter, aggravated by friction. It may be partial or gen- 
eral, and is most common on the back, the outside of the 
limbs, and in the region of the anus and genital organs. 

The most common causes of this affection are improper 
diet and unhygienic living. Prurigo of the anus and 
vulva undoubtedly depends upon obstruction of the portal 
circulation from congestion of the liver. It is commonly 
present in persons of intemperate habits, and is frequently 
very severe and recurrent during the menopause. 

Eruptions which appear at puberty have been known 
to come again at the menopause, while in the mean time 
the patient has been free from any similar affection. 
Some writers on diseases of the skin have recognized the 
reflex nature of some of the dermatoses, but they simply 
consider them part of the general morbid condition. Many 
of the digestive and sexual changes in women are accom- 
panied by disorders of the skin. It is common to see 
women affected with uterine or digestive disorder suffer- 
ing at the same time from eczema facialis, acne, or urticaria, 



THE REFLEX DERMATOSES. 151 

which does not subside under the ordinary forms of treat- 
ment, and only disappears on removal of the uterine or 
digestive disorder. Reflex dermatoses dependent upon 
the menstrual disturbance manifest themselves some- 
times by a small red surface on the side of the nose, cheek, 
chin, or other portions of the surface of the body. These 
patches may be erythematous, or sometimes pustular in 
their nature. Others are diffuse inflammatory eruptions, 
and are called by some physicians chronic recurrent erysip- 
elas (the erysipele catameniel of the French writers). 
There is, however, nothing erysipelatous about the eruption. 
Ecchymoses and hemorrhagic spots have been noted by 
writers as recurring regularly at the menstrual period.. 
The causative connection between catarrhal conditions of 
the uterine or digestive organs and these cutaneous erup- 
tions is readily distinguished. A case is on record of a 
young woman whose first appearance of menstruation 
was accompanied by hemorrhagic perspirations which 
recurred regularly at each menstrual period until she be- 
came pregnant, when the perspirations ceased, never to 
return. 

Symptomatic chloasmata are always dependent upon 
some internal disorder. Chloasma uterinum generally 
appears as a brownish discoloration on the abdomen, fore- 
head, or cheeks. Sometimes it is so pronounced that the 
patient appears as if wearing a mask. This affection may 
present a very dark hue, even black, or the discoloration 
may be so light in color as to be scarcely noticeable. 
Cutaneous discolorations of this type are common in 
patients with digestive disorders and in those suffering 
from cancerous affections. 

Reflex dermatoses as a rule receive but slight attention 
from the gynecologist. Sudden changes of the complexion 



152 FUNCTIONAL NERVOUS DISORDERS. 

of a most marked character are readily recognized by even 
the laity as a result of the correction of digestive disease, 
or as following a beneficial operation upon the uterus or 
its appendages. 

The sallow countenance present in liver derangements 
may be a true neurosis. It generally yields readily to the 
treatment of the causative hepatic disorder. In some cases 
of pregnancy the pigmentation does not extend beyond the 
linea alba and the areola of the breasts, while in a great 
number of others the face is as strongly marked. 

Among the common dermatoses of puberty are acne and 
seborrhcea. Acne is more often functional than organic. 
It occurs usually about the establishment of puberty, and is 
dependent upon physiological changes that have a patho- 
logical accompaniment; it is also commonly induced by 
digestive derangements, and exists as a dermatic reflex in 
patients who indulge freely in alcohol, and in those with 
some forms of dyspepsia. Uterine disease is sometimes 
productive of acne in its severest form. 

Seborrhcea is sometimes dependent upon disorders of 
digestion alone, while at other times pathological condi- 
tions of the genital apparatus are its causative agents. 
Attention to regimen, laxatives, and local uterine treat- 
ment rarely fail in causing its speedy removal. 

The beautiful complexions of girls with perfect digestive 
apparatus are most commonly seen in the youthful peasant 
emigrants from Great Britain and Ireland arriving on 
our shores. This is not alone the result of good nutrition 
and healthy blood, but is a proof that no uterine or diges- 
tive derangement exists to cause neurotic disturbances in 
the appearance of the skin. 

In some forms of uterine disease the abdomen may turn 
almost black, while in others it is mottled or grayish in 



THE KEFLEX DERMATOSES. 153 

appearance. This pigmentation disappears when proper 
treatment is instituted. 

Acne rosacea in a severe form is a very common com- 
plaint with farmers' wives who live upon a bad diet, con- 
sisting of fried meats and an abundance of indigestible 
pastry. Herpes of the pudenda has been noted in cases of 
metritis, and is here undoubtedly a reflex nervous symptom. 

In patients suffering from dysmenorrhcea, tumefactions 
about the size of a small walnut frequently appear in vari- 
ous parts of the body as reflex manifestations. In some 
of these patients at the menstrual period the breasts become 
intensely painful, and there is often numbness and tingling 
of the fingers. 

Mrs. P. (Fig. 13), aged 42, has been subsisting for a con- 
siderable time upon indigestible, badly cooked carbohy- 
drate food. She is quite weak and unable to do any phys- 
ical labor without resting frequently. Every afternoon she 
is obliged from exhaustion to lie down for a number of 
hours. She is mentally depressed, and suffers much from 
fermentative dyspepsia, flatulence being an exceedingly 
annoying symptom. Her chest is covered by patches of 
chloasma, circular in form, and varying in size from that 
of a pea to an orange; the color is brown. Under treat- 
ment directed to her liver and rectifying her diet, these dis- 
colorations rapidly disappeared. She was given a drachm 
of sodium phosphate in hot water, three times daily, an hour 
before food. 

A Menstrual Dermato- Neurosis. — Fig. 14 illustrates 
a case of menstrual dermato-neurosis of the face which 
came under the care of Dr. George M. Edebohls, and was 
reported by him (Transactions of the New York Obstet- 
rical Society, November 15th, 1892). Between the ages 
of fifteen and nineteen this patient suffered from dysmen- 
orrhcea and an eruption on the right side of the face, as 
seen in the illustration. There was an interval of eight 



154 



FUNCTIONAL NERVOUS DISORDERS. 



months when she was about eighteen, during which neither 
the eruption nor the dysmenorrhoea appeared. Dr. Ede- 
bohls treated her on December 22d, 1891, for endometritis 




Fig. 13. 



and catarrhal salpingitis, by dilatation of the cervix, 
curettage, and gauze-drainage of the uterus. The result 
was the complete disappearance of the dysmenorrhoea and 
eruption for the space of three months. They reappeared 
again, and three months later he found, on examination, 



THE KEFLEX DERMATOSES. 



155 



small cystomata of both ovaries, which had not been 
present before. On June 28th, 1892, he performed double 
ovariotomy and ventro-fixation of the uterus. Two poly- 
cysts, one of the left ovary, ten centimetres in diameter, 
and one of the right, six centimetres in diameter, were re- 
moved. Since the operation, six months ago, the patient 




Fig. 14. 

has not menstruated or suffered any pelvic pain. The 
eruption of the face, however, has returned regularly every 
month, and is rather more pronounced than formerly. 
On one occasion it extended around to the left side of the 
face. 

The future developments will demonstrate whether the 
phenomenon is to be regarded as a molimen menstruate. 



Treatment. — The curative measures must be first di- 
rected to the correction of the mode of living and general 



156 FUNCTIONAL NERVOUS DISORDERS. 

hygiene, when these are found to be improper. The diet 
should be nourishing but not too stimulating, and the use 
of all alcoholic beverages should be strictly forbidden. 
Alkaline baths should be taken, and the strictest cleanli- 
ness enforced. 

With regard to internal treatment, the dilute hydro- 
chloric acid before meals will be found very beneficial, as 
will also strychnine. Arsenic may be often used with ad- 
vantage in the form of either Fowler's or Donovan's solu- 
tion. The bowels should be carefully regulated. The 
local measures, for the purpose of allaying the itching when 
present, may be the application of lotions or salves. A 
wash of liquor plumbi subacetatis with a little opium may 
be employed, or one containing bichloride of mercury or, 
better still, a strong emulsion of kretol (this is especially 
useful in pruritus ani) . Ointments, made on the same prin- 
ciples, or containing belladonna, camphor, or opium, may 
also be used, and are often of service when the lotions fail 
to give relief. 



CHAPTER XIX. 
HYSTERIA. 

Among the imitations of organic disease which, in one 
or another of its many forms, we are liable at any time to 
meet in our practice, is hysteria. Any or every part of 
the body may, under the influence of the nervous system, 
be its seat ; in my opinion it has not received the careful 
attention which it deserves, although much has been writ- 
ten upon the subject. There are many physicians engaged 
in active practice who give it scarcely a passing thought. 
The mind of the average practitioner is taken up with the 
pathological changes going on in the body. Congestion, 
inflammation, and their results attract all his attention, 
and he almost altogether ignores functional disturbances. 

Hysteria is an objectionable name, as the brain rather 
than the uterus is the organ involved. To find a suitable 
substitute, however, is extremely difficult; common usage 
has given the name hysteria to certain forms of nervous 
irritation, and we therefore accept it. 

Many cases of spinal tenderness, which is a simple func- 
tional disorder, a reflex from digestive or other abdominal 
disturbance, have been supposed to be local or other in- 
flammatory diseases, and have been treated by confinement 
to bed, blisters, and other local remedies, when no disease 
was present in the part under observation. 

Contractures of the hand or foot, of supposed organic 

origin, have often been met with, when hysteria was alone 

157 



158 FUNCTIONAL NERVOUS DISORDERS. 

the cause of their production. A very large number of the 
diseases in women of all classes is of hysterical origin. 
This explains the marvellous results obtained from the 
many and various methods of treatment in vogue; at 
present electricity is the general cure-all, and a short time 
hence some other medical fad will probably be the fashion. 
Simulated or unconsciously feigned disease might be said 
to be the rule, while inflammatory disease is the exception. 
Hysteria may usually be traced to some constitutional 
weakness or to exhaustion of mind or body with some ac- 
companying marked mental emotion. Anything which 
powerfully excites the intellectual sphere, such as severe 
mental shock, excessive stimulation and indulgence of the 
imagination and emotions, tends to the development of 
hysteria. 

Hysteria occurs frequently in epidemics, of which med- 
ical history gives several examples. Life in dreary mo- 
notonous surroundings, such as prisons or isolated farms, 
results in the production of much hysteria and insanity. 
From the never-changing gloom, the lack of social inter- 
course, and the ceaseless repetition of a daily routine, these 
surroundings are as destructive to mental as to physical 
health. The hysterical are as a rule anaemic, nervous 
people, who are fretful, emotional, and quick-tempered. 
It is not alone the emaciated ansemics who suffer from the 
disease, but fat women with hydrsemia are its frequent 
victims. Impaired digestion, the result of defective hy- 
giene and bad cookery, is a primary cause of anaemia, and 
the basis of most of the cases under consideration. 

The seeds of hysteria exist in the great majority of 
women : whether it develops, or how it develops, depends 
upon the individual peculiarities of each case. Hereditary 
taint plays a very considerable part in the development of 



HYSTERIA. 159 

this disorder, mothers in very many instances transmit- 
ting such weaknesses to their daughters. When there is 
insanity in a family, it also predisposes the female mem- 
bers to hysteria, as will also any nervous disease in the 
mother. 

Age is a predisposing cause, by far the largest propor- 
tion of cases occurring from the accession to the cessation 
of menstrual life, at both of which periods its attacks are 
much more severe than at any other time. Precocious de- 
velopment of the intellect in children, and allowing them 
to mix too much in the society of their elders, taking them 
to theatrical representations, balls, parties, etc., thus un- 
duly stimulating and exciting their nervous systems at an 
early period, exaggerate their sensibility and make their 
constitutions fertile soil for the development and growth 
of the seeds of hysterical disorder. 

Climate plays no inconsiderable part in the development 
of hysteria, which, according to many writers, is most 
common in extreme northern and southern latitudes, and 
especially in those countries where women menstruate at 
a very early age. In large cities hysteria is much more 
common than in the country. 

Sedentary occupations, improper diet, impure air, lack 
of sufficient bodily exercise, constant brooding over relig- 
ious subjects, and any other circumstances which tend to 
lower the tone of the nervous system, may be ranked 
among the exciting causes of hysteria. 

Irritations of the genital apparatus, especially a perver- 
sion of the sexual functions, are also fruitful sources of 
this disorder. The victims of sexual perverts, either male 
or female, often suffer from very severe attacks of hys- 
teria. 

Hysteria is most common in young women and girls, 



160 FUNCTIONAL NERVOUS DISORDERS. 

but is not by any means confined to them, as we find it in 
women of forty or fifty, and rarely in young men and boys. 
In all of these patients the health is in a poor condition ; 
the circulation is weak, the tone of the nervous system is 
lowered and. unstrung, and a great variety of morbid sen- 
sations are present. The blood being impoverished, the 
brain suffers from anaemia, and irresolution and weakness 
take the place of self-confidence and mental strength. 
These patients are nervous and excitable and are liable to 
sudden disturbances of the emotions without apparent 
cause. 

Much of the illness prevalent is factitious ; people who 
are not compelled to work hard for a living having time 
to indulge their morbid fancies. Many of the poor have 
no time to consider their sensations, but must work on ac- 
tively in spite of weariness and fatigue. Much supposed 
muscular weakness or weariness is in reality mental. 
The hunter, tired after a long and unsuccessful chase, sud- 
denly discovers game in the distance; fatigue and ex- 
haustion immediately vanish, and miles are again covered 
by him with pleasure and a sensation of lightness, the 
mind having overcome the body. 

The view held by Dr. Bristowe with respect to hysteria 
and other functional nervous diseases and their mutual 
relationship was that there are many functional diseases 
of the nervous system, among which may be included 
many forms of insanity, the different classes of epilepsy, 
chorea, migraine, neuralgia, and hysteria. All of these 
are characterized by groups of symptoms referable to ex- 
citement, depression, or aberration of the nervous func- 
tions, and mainly those of the nervous centres. They are 
severally distinguished clinically by the association of 
definite groups of symptoms, determined either by the 



HYSTERIA. 161 

particular part of the nervous system affected, by the spe- 
cial kind of affection which takes place therein, or by the 
order and mutual relation of events. They are regarded 
as specific diseases, because experience teaches us that 
such groups of symptoms are so commonly observed under 
particular conditions as to show that specific causes must 
underlie them and determine their occurrence. But the 
causes of the affections are for the most part closely related 
to one another, if not identical; the individual symptoms, 
which by their modes of aggregation constitute the sev- 
eral diseases as we know them are common in a greater or 
less degree to all of them. Many cases occur in which it 
is difficult, if not impossible, to determine satisfactorily in 
which category they should be placed, and indeed there is 
no substantial line of demarcation between the diseases. 

Dr. Bristowe further holds that hysteria represents an 
unstable condition of the nervous functions, that is inde- 
pendent of any organic change in the nervous system, in 
which, at one time or another, one or more of its part 
may be temporarily affected in one of various ways. 
There is, as a rule, little difficulty in diagnosis, owing 
partly to the conditions under which the symptoms of the 
disease arise, partly to the emotional state which is usu- 
ally present, and partly to peculiarities in the symptoms 
themselves. 

Among the sensory disturbances which occur in hys- 
teria are anaesthesia, hyperaesthesia, and neuralgia. 
Sometimes the disturbance is local, at other times quite 
general. The anaesthesia is most frequent on the left side, 
and may be coincident with analgesia. Hemianaesthesia, 
occurring with contracture, is frequently connected with 
one-sided ovarian pain. The anaesthesia is usually con- 
fined to the integument, but when it is very profound, the 
11 



162 FUNCTIONAL NERVOUS DISORDERS. 

muscular tissue and mucous membranes become involved, 
thus causing loss of taste and smell. Hearing and sight 
may also become deficient when there is anaesthesia of 
the retina. 

Hyperesthesia may be limited to the skin of the hands 
and feet or the scalp; it may also occur in patches over 
the front of the chest and abdomen. Hypersesthesia of the 
joints is noted under the head of joint neuroses. These 
pains in the joints are sometimes accompanied by oedema 
and swelling of the tissues, thus simulating rheumatic in- 
flammation. When the special senses are involved, the 
eye is extremely sensitive to light and hearing is markedly 
exaggerated, so that the slightest sound, such as the rus- 
tling of a newspaper is greatly magnified, the patient im- 
agining that the paper is being violentl} 7 torn to pieces. 
The ticking of a clock may be extremely annoying from 
its apparent loudness, and even the ticking of a watch 
may be distressing. Patients with hypersesthesia of the 
sense of hearing are much annoyed by the fact of a person 
walking behind them; the footfall seems to them to be 
very noisy, and they imagine that they are being pursued 
and that the person following them is about to rush upon 
them with great force. This condition of nervousness is 
apt to be produced by the excessive use of hot baths and 
improper feeding. 

Hysterical neuralgias which are accompanied by other 
signs of hysteria undergo rapid modifications as regards 
their severity and location. After much excitement, or 
after convulsions, these neuralgias may occur along the 
course of certain nerves, most frequently in the temporal, 
frontal, occipital, or auricular regions. Hemicrania of 
the left side is a very common occurrence in hysteria. 
Neuralgias may also be met with in other situations. 



HYSTERIA. 163 

Enteralgia and cardialgia are frequently observed, but 
the most usual seat of pain in these cases is the ovaries. 
The ovary may, or may not, be enlarged. It is claimed 
by Charcot that pressure over the region of the ovary will 
moderate and often stop the convulsion of hystero-epi- 
lepsy. I have found, however, that pressure increases the 
severity of the convulsion, and has an effect similar to 
pressure of the ovary itself, which, as Charcot has stated, 
is often sufficient to induce the hystero-epileptic attack. 
A case quoted in the " Iconographie de la Salpetriere" has 
seemed to me of sufficient interest to be given somewhat in 
detail. 

"In November, 1887, Gilles de la Tourette found 
a young hysterical girl in a ward of the Salpetriere. 
Among the other symptoms of her nervous affection she 
had a spasmodic contraction of the upper and lower lid 
of the left eye. She first came for treatment on the 22d of 
September. Her father had a rheumatic diathesis, her 
mother died of heart disease, and her sister suffers from 
hysteria. She herself had measles in childhood, and at 
seven years of age Sydenham's chorea appeared and lasted 
five years. At fifteen years she first menstruated. On 
July 1st, 1887, she caught cold, had a sore throat, and felt 
a stiffness in her neck. The next morning she was speech- 
less and could not swallow. At the end of a week the 
throat was better, but her voice had not returned, and in 
addition she had pain in her knee, and markedly in the 
right hip. During this trouble she had also had three or 
four convulsive attacks. La Tourette found that by pres- 
sing upon the eyeballs she was easily put into a light 
hypnotic sleep. In this condition she was able to speak 
and was entirely free from suffering ; in a more profound 
sleep the same results were obtained. As the result of one 
of her attacks in the month of November, the left eye re- 
mained closed and the patient fancied that the lid was 
more tightly held down as time went on. She had never 



164 FUNCTIONAL NERVOUS DISORDERS. 

seen any one suffering from blepharospasm. Her condi- 
tion on the 27th of November is as follows : 

" She is still voiceless, suffers pain in the left hip, and her 
left eye is still affected. She can feel cold and the prick 
of a pin and can recognize touch all over the right side of 
the body, with diminution in sensitiveness in the right 
hand extending four fingers' breadth above the wrist. 
The left side is less sensitive to touch and cold than the 
right. There is a zone of analgesia and anaesthesia ex- 
tending the whole length of the left arm. As to the left 
leg it is a little less sensitive than the right. The left 
half of the scalp is anaesthetic; pressure upon the left 
ovary produces a spasm. Hearing is less acute on the 
left side; the left eye is amaurotic, there is nothing abnor 
mal in the fundus, and the pupil reacts to light. In the 
right eye the visual field is narrowed (-§-§-) , but there is 
no dyschromatopsy. Upon applying Esmarch's band to 
the wrist the hand becomes flexed ; if suddenly stretched, 
the arms remain in extension. No amount of personal 
effort avails to open the left eye, and quite a resistance is 
perceptible upon forcible lifting of the lid. Touching the 
cornea causes lacrymation, but no feeling of pain. Hyp- 
notic suggestion was begun upon the 27th of November, 
and about the first of December the patient's voice returns 
and her eyelid opens, but the eye is still very weak. 
After a few hours' interval sight is completely lost in that 
eye ; hypnotic suggestions are made every morning. 

"The hysterical attacks continued until June, 1888, but 
in December of that same year when she left the hospital 
she was not entirely cured." 

Richer has noticed a number of cases similar to the one 
described. The blepharospasm is at times clonic, and 
again tonic in nature; a third variety is called pseudo- 
paralytic. Amaurosis, complete or incomplete, always 
exists in hysterical blepharospasm. In almost all cases of 
hysteria there is present an exaggeration of motor excita- 



HYSTERIA. 165 

bility which varies in degree from quick, precipitate move- 
ments to contractions of a single muscle or an entire 
group, and in some cases it may even pass into convul- 
sions. Strabismus (convergent or divergent), with spasms 
of the optic muscles, and spasmodic twitchings and con- 
tractions of the muscles of the face are manifestations 
which we find in hysterical patients in the region of the 
head. 

Hysterical aphonia in emotional young girls is at times 
associated with hysterical squint. The French writers 
have especially noted the narrowing of the palpebral fis- 
sure (hysterical blepharospasm) , with contraction or twitch- 
ing of the muscles of the same side of the face accompany- 
ing the condition ; hysterical anorexia, vomiting and even 
convulsions may also be present. The same side of the 
body is usually the seat of complete ausesthesia; not only 
feeling but taste and smell are deficient, and the percep- 
tion of color in the corresponding eye is imperfect or abol- 
ished. The ovarian region, however, is sensitive to pres- 
sure. General chorea, similar to chorea gravidarum, is 
also in some cases an additional source of distress. 

Occasionally the hemianesthesia is replaced by h3 T per- 
aesthesia, or there is, while the patient is under treatment, 
a partial or temporary transference of the condition to the 
other side. 

In the sterno-cleido-mastoid, the trapezius, and other 
muscles of the neck, also in the larynx, pharynx, and 
oesophagus, spasm is often developed in a rapid and severe 
manner. Sometimes the muscles of deglutition are inter- 
fered with, causing severe sensations of choking. 

Hysterical dyspnoea has been known to be so severe that 
tracheotomy has had to be resorted to in order to afford 
relief. This functional affection of the larynx is of an 



166 FUNCTIONAL NERVOUS DISORDERS. 

asthmatic character, and comes on suddenly without rise 
of temperature; it is often accompanied by cough. 

Among the common forms of hysterical manifestations 
in the region of the neck and chest are hysterical laughter, 
shouting, weeping, yawning, cough, and asthma. 

In the abdominal region the hysterical phenomena ob- 
served are borborygmus, hiccough, hysterical eructations, 
regurgitation of food, vomiting, and spasmodic affections 
of the genito-urinary apparatus. 

The attitude and walk in hysterical hemiplegia is de- 
scribed by Gilles de la Tourette as follows : " After taking 
a few steps the patient whose left side is supposed to be 
affected rests his body on his right foot, which is thrown 
a little forward. All tonicity has left the muscles of the 
left leg, and they are partly atrophied ; the leg acts accord- 
ing to the laws of weight and with the thigh forms an 
obtuse angle, strongly limiting the movement of the knee 
ligaments. The left foot is placed in the equino-varus po- 
sition, the heel turned outward, and the point resting on 
the floor on the dorsal side of the first three toes. It is 
perfectly inert, and when the patient is walking is dragged 
after the other foot, all progress being confined to the right 
side." 

Todd in his clinical lectures says : " I particularly 
wish to call your attention to the special character of the 
movement of the paralyzed leg when the patient walks ; in 
my opinion, it is characteristic of the hysterical affection. 
If you watch a person suffering from an ordinary hemi- 
plegia, the result of a cerebral organic lesion, you will no- 
tice that in walking he has a peculiar way of carrying the 
paralyzed limb : the healthy side of the trunk is first car- 
ried forward and supports the weight of the body; then 
by a movement of circumduction the paralyzed limb is 



HYSTERIA. 167 

swung forward, causing the foot to describe the arc of a 
circle. The hysterical patient, on the contrary, drags the 
affected leg as if it were an inanimate object ; there is no 
movement of circumduction, and no effort is made to lift 
the foot, which simply drags upon the floor." 

This absolute paralysis of the limb is characteristic of 
hysteria, and its presence will be of great assistance in 
reaching a diagnosis, should the hysterical stigmata be 
absent. 

In speaking of hysterical contractures Dr. S. Weir Mit- 
chell says : " We do not know what hysteria is. So far 
death has destroyed whatever evidence life might have 
offered as to its existence as an obvious thing capable of 
visual demonstration, and still we are apt sometimes with 
too much confidence to refer back its demonstration to this 
or that centre. Thus it has been taken for granted that 
hysterical contracture is due to disorder somewhere pres- 
ent in such columns of the cord as are usually diseased in 
spastic paralysis. The chief basis upon which this opinion 
rests is this : Cases of long-continued contracture have 
been seen to end in sclerotic alteration of the lateral col- 
umns of the spinal cord. The inference is that the pre- 
cedent functional states were also due to the less visible 
hysterical conditions of the columns. (Soc. rued, des 
Hopitaux, Vol. CXI., 2d series, p. 24, Charcot.) More- 
over, it has been taken for granted that the state of con- 
tracture is analogous to the condition we find present in 
muscles rendered overresponsive by lateral sclerosis. I 
am not at all sure that these inferences are safe, or even 
that contracture is of a certainty due to spinal centres at 
all. It is quite possibly purely local and muscular as to 
origin, and indeed there are reasons why it is extremely 
difficult to consider it as of spinal birth, or in any way 



168 FUNCTIONAL NERVOUS DISORDERS. 

analogous to the state of excitability seen in disease of the 
lateral columns. I have become quite assured that there 
are two forms of hysterical contracture — one apt to be local 
and limited, and not followed by organic muscular changes ; 
the other apt to affect two or more limbs, and almost every 
muscle, even of the trunk, and prone to result in the mus- 
cular and areolar tissue changes already described. I 
think it curious that while the earlier stage of general con- 
tracture is most difficult to cure, when the disease has 
caused organic changes and is in its second stage it is far 
less hard to deal with. Perhaps this may be due in part 
to the disappearance of active hysteria. Indeed it is often 
true that in certain old examples of contracture, the symp- 
tom contracture exists no longer, and we have to deal 
alone with the mischief of originally shortened muscles, 
altered joints, and sclerematous changes in the intermus- 
cular space. The hysteria is lost with years ; the spasm 
lessens or ceases; the consequences and additions remain." 

The causation of this affection is to a degree frequently 
emotional. It comes on sometimes abruptly, and its dura- 
tion may be short, or for the rest of the patient's life. It 
may affect all or several muscles, and all the extremities 
may be involved, as represented in Fig. 16. Sometimes 
the spasm is continuous, again it is intermittent. Local 
ansesthesia is present, as a rule; under ansesthestics, and 
sometimes during sleep in the early simpler cases, there is 
relaxation. After the muscles shorten or harden, there is 
of course no relaxation. General contractures are rare. 

In the treatment of this condition gradual extension by 
instrumental means may be employed, such as extension 
braces with ratchets, or an apparatus with weights. It is 
extremely important that the Weir Mitchell method of 
isolation should be resorted to early in these cases. 



HYSTERIA. 



169 



A careful ophthalmoscopic examination should be made, 
in order to assist in excluding organic disease. Hysteri- 
cal contractures are what we term functional, as no or- 
ganic changes are found in the spinal column as causa- 
tive factors. Under treatment by massage, hydro- or elec- 
tro-therapy, and curative exercise as practised in a Zander 




Fig. 15.— Reflex or " Hysterical " Contraction Due to Gastric Irritation. 

institute, the affected parts often rapidly regain their 
former condition. In some cases tendons will have to be 
cut. 

Hysterical contractures of the sphincters of the vagina, 
bladder, and anus are quite common. Contractures of the 
extremities (see Figs. 16 to 21) often appear after emotional 
excitement or convulsions. Tremblings are also common, 
particularly of the upper extremities; sometimes the lower 
extremities are also involved. When respiration is inter- 
fered with, there may be severe manifestations of dyspnoea, 



170 FUNCTIONAL NERVOUS DISORDERS. ' 

and attacks of asthma and asphyxia in lungs that are nor- 
mal are common reflex hysterical symptoms. Anorexia 
or bulimia is also commonly present. Epigastric pulsa- 
tion, tympanitic distention, constipation, belching, and 
obstinate vomiting are often seen in these patients. Men- 
struation is often disordered ; it may be suppressed, scanty, 
or irregular. 

When there is retention of urine from anaesthesia of the 
vesical mucous membrane in paralysis of the bladder, 
careful catheterization must be employed for a consider- 
able length of time; suppression of the urinary flow (anu- 
ria) or morbidly diminished urinary secretion (oliguria) 
is often noted. 

The following cases I quote from the " Iconographie de 
la Salpetriere, " as I consider them of value in the descrip- 
tion of hysterical manifestations : 

" Paul Richer calls attention to a case of hysterical con- 
tracture of the right leg which deserves mention because 
of the unusual position of the limb, and because of its re- 
sistance to all treatment, including hydrotherapy and mag- 
netism . 

" The patient, seen in February, 1882, was a young girl 
of fifteen years, with no other history than that of an im- 
petiginous eczema of the face and hands during childhood 
(being covered with an eruption until the age of seven;, 
and frequently occurring attacks of ophthalmia. There 
was no history of nervous antecedents in the family. 

" Four years previously, at the age of eleven, during a 
railway journey, she claims to have gone to sleep in a 
twisted position, or she may have taken cold. The follow- 
ing day intense pain was felt in the right hip, which 
seems to have persisted for several days. Before she left 
her bed a stiffness of her right leg was noticed, and a few 
days later the right arm was affected in the same way. 
The position of the arm was that of flexion, the fingers 



HYSTERIA. 171 

bent inward, the hand bent upon the forearm, and the 
forearm upon the arm in inward rotation and adduction 
in such a manner that it was placed transversely behind 
the back. 

" The lower limb was in a position of extension, the thigh 
extended upon the leg and pelvis, the foot in extension. 
Eighteen months later the condition gradually improved, 
and in a few weeks showed no trace of stiffness. The leg, 
however, remained in a state of contracture, so that the 
patient was unable to sit down ; she was obliged to eat in 
a standing posture, and in walking trod upon the heel, the 
toes being elevated. Any effort to lower the toes or to 
flex the leg upon the thigh increased the rigidity of the 
muscles. The right leg was by measurement found to be 
4.5 cm. smaller than the left, the right thigh 1.5 cm. 
smaller than the other. During sleep the contracture en- 
tirely disappeared, but returned at once upon waking, and 
even when sleep was light or disturbed. Dr. Sayre, of 
New York, endeavored to overcome the condition by 
forced flexion ; a plaster dressing was tried, but as soon 
as it was removed the contracture reappeared. The ma- 
nipulations and dressings caused intense pain." 

A case under Delprat's charge in Amsterdam is inter- 
esting. 

"A young girl of seventeen, previously strong, and 
with no personal history of neurosis, but belonging to a 
very nervous family, came in February, 1891, for treat- 
ment for her face, which was affected with bilateral con- 
tracture. The trouble dated from the previous August, 
when it started with toothache of the left upper incisors. 
After a month's duration of the pain, the patient noticed 
that the left side of her face was at times subject to con- 
tractures. These were at first temporary, lasting from 
one-half hour to three hours and a half, and occurred sev- 
eral times in the twenty-four hours. After a month's 
duration they spread to the right side of the face. A de- 



172 FUNCTIONAL NERVOUS DISORDERS. 

cayed incisor was taken out, but the face remained in the 
same condition. 

" The patient is anaemic, too tall for her age, thin, and 
has a laughing, bizarre expression. The labial commis- 
sure is elevated on the right side, and lowered on the left, 
the nasal groove being more marked on the right side. 
At first sight one is forcibly reminded of facial hemi- 
plegia. The right eye looks smaller than the left, which 
is due to a slight contraction of the right palpebral orbi- 
cularis. Upon a careful examination it is seen that the 
contraction is also quite evident on the left side. In 
breathing the cheek is not flabby as if inert, the air escap- 
ing more easily on the right side. In opening the mouth, 
the opening is larger on the right side than on the left ; 
the tongue is protruded without deviation, and is freely 
movable. When the left side is covered, the expression 
on the other appears to be that of a laughing disdain. 
The expression of the left side is sad and dull. If the 
mouth be energetically rubbed, the contraction disappears 
and the expression becomes normal. After a few seconds 
of rest, a twitching begins in the levator labii superioris 
alseque nasi, and in the zygomaticus major of the right 
side. After each tremor the degree of contraction in- 
creases until it becomes fixed. At the same time contrac- 
tions are seen in the levator menti of the left side, and the 
chin is somewhat elevated. The left labial commissure is 
a trifle lowered, the upper lip becomes stiff, the ala nasi is 
depressed, and the lower lip protrudes slightly beyond the 
upper. All this happens in about two minutes' time. 
Even in sleep the contracture persists. The decayed teeth 
seem to have been the cause of the trouble in this case. 
The patient is highly hysterical ; she has a hemi-farado- 
cutaneous anaesthesia on the left side (face, arm, and leg). 
Upon the left side she feels the electric brush only when 
it is applied with more force than on the right. 

" In the treatment of this patient suggestion was used 
without hypnotic sleep. Her willingness to aid in the 
treatment was of great assistance. Suggestion was con- 



HYSTERIA. 173 

tinued for about eight weeks, and four months later there 
was an apparently perfect cure." 

Paul Richer thus describes the diathesis of hysterical 
contracture: "The victim of this trouble presents no 
objective sign; he preserves freedom of movement, the 
manifestations of his trouble being always brought about 
by the manipulations of the physician or by some chance 
occurrence. This condition of the neuro-muscular sys- 
tem partakes of paralysis in that it usually coincides with 
a weakness of motility, and of contracture in that the 
slightest excitement will bring it on or cause it to dis- 
appear. This diathesis is found outside of hysteria. It 
has been called ' latent contracture.' Its principal points 
are: 

"1. Exaggeration of the tendon reflexes. This is con- 
stant but variable in degree. 

" 2. Epileptoid tremblings. This may occur, but very 
rarely. 

" 3. The muscles react to electricity, but in a modified 
degree. 

" A. When the interruptions of the electrical current are 
rapid, the muscles are tetanized as in health, but in hys- 
teria the muscles acted upon are not the only ones con- 
tracted. 

" B. If the interruptions are slow, the muscular twitch- 
ings are at first slow and distinct, but finally become 
continuous. 

" C. There are certain irregularities in the muscular 
twitchings : 

" a. Myographic readings show a lengthening of the de- 
scending curve. 

" b. At times a single electric shock will bring on a per- 



174 FUNCTIONAL NERVOUS DISORDERS. 

manent contraction, in which case the descending curve is 
incomplete, and the muscle remains in a state of contrac- 
ture. 

" c. As a rule several shocks are needed to give this per- 
manent contracture. 

" 4. Contractures are brought on by : 

" Deep muscular massage. 

"A succession of raps upon the tendon. 

" Stretching and flexion of the limbs. 

" Injury to a nerve. 

" Application of a vibrating tuning-fork. 

" Faradization of the muscles or nerves. 

" Magnetism. 

" Superficial excitement of the skin by light pressure. 

" Suggestion while the patient is awake. 

" These various methods are not of equal efficacy." 

Sollier and Malapert speak in the following manner of 
voluntary contraction in a hysterical patient : 

" Contraction, whether organic or the result of experi- 
mentation, may be defined as a pathological state of the 
muscle characterized by an. involuntary and continuous 
rigidity. A man thirty-five 3 7 ears old, an acrobat by pro- 
fession, has suffered a slight muscular rupture of one of 
the adductors of the thigh. His father was not of a ner- 
vous temperament; the mother suffered from migraine 
and an aunt was somnambulistic. The patient himself 
has met with several professional accidents ; at the age of 
sixteen he was operated upon for a tuberculous testicle. 

" His health is good, although he is a heavy drinker and 
suffers from alcoholic tremors ; strange to say, he has but 
little strength in his arms. The peculiarity which he 
possesses is that he can at will induce a contracted con- 
dition of certain muscles. He stretches his arm horizon- 



HYSTERIA. 175 

tally, the anterior surface turned upward with his five 
fingers in apposition at the tips. While he watches his 
arm with great attention, the flexors forcibly contract, 
and are followed by the supinator, brachialis anticus, and 
finally the posterior muscles. The forearm meanwhile is 
affected with increasingly severe spasmodic twitchings. 
Then suddenly the hand is placed in forced pronation, and 
then it and the forearm are placed in forced extension. 
The arm drops alongside of the body at an angle of 20° ; 
the whole proceeding has taken from ten to fifteen seconds. 
In the condition described the muscles of the hand and 
those of the forearm are absolutely contracted, the contrac- 
tion diminishing from the distal extremity to the origin 
of the limb. The extended fingers cannot be closed. The 
wrist can be moved a little, the elbow a trifle more freely, 
and the shoulder still more readily. The flexors of the 
fingers are hard and contracted, but less so than the exten- 
sors. This state of contraction may last for more than 
an hour, and can be brought on at will, the patient feeling 
no cramps at all. He can act upon the abdominal muscles 
in the same way. He first contracts the recti abdominis, 
and as the thorax enlarges the intestines seem displaced 
upward. The abdomen is then suddenly depressed and 
the whole intestinal mass is pushed upward, all the organs 
being displaced. It is possible for the patient to walk, talk, 
eat and drink in this condition, which lasts from ten to fif- 
teen minutes. In putting an end to this performance he 
proceeds slowly, the whole mass sinking gradually into 
position. 

"This man is a typical hysteric. His pharynx has 
no sensibility, as is proved by the power he possesses 
of swallowing glass; at times he has a globus in the 
region of the right floating ribs. He is deaf in the left ear 



176 FUNCTIONAL NERVOUS DISORDERS. 

and slightly so in the right. His sense of taste is much 
impaired." 

In hysteria both circulatory and respiratory symptoms 
or disorders are common. Pulsations of the abdominal 
aorta, which, owing to a stiffness of the abdominal walls 
from local inflammatory states are readily transmitted to 
the palpating hand, are often in these cases mistaken for 
aneurism. Tachycardia, or rather palpitation and irregular 
beating of the heart, are also common, the rate of beating 
sometimes going as high as two hundred in the minute. 
" In severe attacks of hysteria, swelling of the neck is of 
frequent occurrence, but it is seldom seen as a permanent 
symptom between the paroxysms. Richer has seen one 
case at the Salpetriere. It is the result of blood stasis, 
itself the result of respiratory and muscular spasm. The 
stopping of respiration stops the call for venous blood to 
the thorax which is produced by every respiratory move- 
ment; the contracted muscles compress the veins of the 
neck as they enter the chest and more or less interfere with 
the flow of blood. As the neck enlarges the tissues become 
congested, the superficial veins enlarge and bulge out under 
the skin ; this congestion spreads to the face, the lips, the 
eyes, etc. These phenomena are at times so striking that 
they give a special character to hysteria." 

Emile Boix gives a case of blue hysterical oedema : 

" The patient is a man of thirty-five years. There is a 
history of neuralgia in some members of the family. The 
patient was troubled with incontinence of urine up to the 
age of fourteen years. He has had three attacks of rheu- 
matism, and has twice had facial erysipelas. There is no 
history of specific trouble. In August, 1888, he had pain- 
ful cramps in the right hand, especially when attempting 
to grasp any object ; then the hand became cold, pale, and 



HYSTERIA. 177 

numb, so that he was unable to use it. On the fourth 
morning after the onset of the attack, the hand was enor- 
mously swollen. He then entered the hospital, and pre- 
sented the following symptoms : His right arm was par- 
alyzed, the hand cedematous, cold, and bluish in color, 
stiff, with absolute absence of feeling in the fingers. The 
pharynx was also anaesthetic ; the eyes were normal and 
there was no other perceptible trouble. 

" The patient was put under the influence of chloroform, 
and the hand turned pinkish in hue; its temperature was 
higher than that of the left hand. It remained quite stiff, 
which was doubtless due to the rheumatic trouble, as there 
were fibrous bands present; sensibility returned and the 
paralysis and oedema disappeared, all within the twenty- 
four hours. 

" On January 1st, 1890, the man returned to the hospital, 
again complaining of the swelling in his hand ; the thumb 
was also involved, as well as half of the forearm. In 
March the oedema had disappeared, only to reappear in 
August. In December of the same year the condition of 
the patient is as follows. He is a tall, fair man, with blue 
eyes; his hair is scrupulously parted and his moustache 
curled ; his voice is altered ; in short he has the character- 
istic appearance of an hysteric. The muscular develop- 
ment is only medium ; his right hand only is affected, the 
arm seems paralyzed, the patellar reflex is normal. On 
his right side he is insensible to touch, and the sensibility 
to heat and cold is much diminished; the pharynx is still 
anaesthetic, this anaesthesia being shared by one half of 
the tongue, the right nostril, conjunctiva, and ear. Taste, 
smell, and sight are affected upon the right side. The 
hand, especially upon the dorsal aspect, is swollen, almost 
to bursting; its color is still blue. The oedema is not 
affected by position, and, although it pits on pressure, the 
swelling immediately returns. The hand is absolutely 
insensible; it remains in a flexed position, and when an 
attempt is made to move the fingers the muscles of the 
forearm are affected as in spinal epilepsy. At times there 
12 



178 FUNCTIONAL NERVOUS DISORDERS. 

is a rhythmic tremulousness of the hand. There is exces- 
sive perspiration of the right axilla. 

" Three facts are worthy of ©special notice in this case. 

" 1. The coloration of the hand was changeable, passing 
from a violaceous blue to a whitish tinge, as in the case of 
oedema due to a cardio-renal lesion. 

" 2. Although the oedema felt hard, the fact that it would 
pit upon pressure made it probable that it was elastic 
oedema. 

"3. The temperature of the hand was found to vary in 
its different parts, the variation at times being as much 
as 16.4°. 

" The suggestion that the effect of hypnotism should be 
tried appears to have alarmed the patient, and to have 
caused his disappearance. He was evidently averse to 
having the condition cured, as it obtained support for him 
in the hospitals." 

Wallet gives this description of hysterical anorexia. 

" This is found only in young girls, usually between the 
ages of twelve and fifteen. When present, it is usually 
the only symptom of hysteria. Its persistence and the 
rate at which it increases unless promptly and energeti- 
cally treated would lead one to believe that it was due 
to a nervous degeneration. 

" It is of indefinite duration, and when weakly indulgent 
parents do nothing to overcome the obstinacy of the 
patient, as sometimes happens, death is the result. The 
weakened condition of the patient makes her an easy 
victim to disease, more especially tuberculosis. To quote 
a case in point : 

"Miss B., seventeen years of age, was brought to the 
Auteuil Hydrotherapeutic Institute in a terribly emaci- 
ated condition. All the bones were plainly visible, the 
muscles were easily felt, the skin was dull and lifeless, 
cold and clammy. Her eyes were sunken, lips swollen, 



HYSTERIA. ' 179 

tongue coated, and breath foul. The skin of the legs was 
blotched in appearance; there was slight oedema of the 
feet and ankles, which pitted on pressure. The patient 
was very constipated, and her menstruation had ceased. 
The visual field was slightly diminished. She was very 
fond of walking, and this exercise was allowed her on the 
condition that she would consent to take her food. As 
no improvement followed, long walks were forbidden, and 
she was not allowed to go beyond the boundaries of the 
garden; even this limited amount of exercise had to be 
stopped, the patient confined to her room, and finally to 
her bed. She still contrived to get more exercise than 
was good for her, as she had the fixed notion that repose 
would fatten her, and she thought that her looks were im- 
proved by extreme thinness. After six weeks' treatment 
menstruation reappeared, and her weight increased from 
27 to 34 kilos." 

Hysterical fever, as the result of nervous excitement, 
usually begins with a chill which is followed by the fever- 
ish symptoms; these are usually confined to the face and 
head. The patients easily become delirious, and may have 
tremor or convulsions; the mouth is dry and the appetite 
impaired. The temperature rises, and the pulse increases 
from normal to 100 or 120 a minute. 

Under the head of vascular secretory neuroses may be 
placed hysterical salivation. It is not common, but has 
occasionally occurred. 

Hysterical psychoses manifest themselves in the lighter 
forms by excitability and great sensitiveness to matters 
of minor moment; by sudden changes from sadness to 
gayety, or by attacks of sullenness and obstinacy. In the 
more pronounced forms, melancholia or mania may de- 
velop. 

Brissaut and Souques report the following case of delir- 
ium of hysteria. 



180 FUNCTIONAL NEBVOUS DISOEDEES. 

"A young girl, 9 years of age, of nervous origin, fell 
upon her right hip, and as a consequence had pain, swell- 
ing, and redness of the parts. The swelling subsided, 
but left in its place a psychical hyperesthesia which lasted 
for ten years. It showed itself in various ways, such as 
vomitings, swelling of the abdomen, and attacks of un- 
consciousness. 

" Through a mistake in diagnosis she was at first treated 
for coxalgia, then for abscess with peritonitis, and was on 
the point of being treated by laparotomy. It was really a 
case of hysterical simulation, probably induced by the 
questioning, explorations, and treatment of the ph} T sician. 

" At the age of thirteen, injudicious friends began to tease 
her about getting fat, and thus she became impressed with 
the desire to become thin. Her method of attaining this 
end was to eat as little as possible and to vomit all that 
she did eat. For some time her wish to grow thin was 
somewhat latent, although a fixed idea, but at the age of 
sixteen the teasing became too much for her to bear, and 
she absolutely refused food. She became alarmingly 
emaciated, and was several times at the point of death. 
In an ecstatic religious state she sought help at Lourdes, 
and the first time apparently received benefit; the second 
time, however, the pilgrimage did her no good, and this 
fact threw her into a state of despondency, as she imagined 
that she must have fallen from grace, probably because of 
unconfessed sins. This despondency changed into a fixed 
mania. Under treatment she gained thirty kilos in 
weight in three months' time. This sudden regaining of 
fat is seen only in hysterical patients." 

In somnambulism of hysterical origin, as in the ordinary 
type of somnambulism, the supervision of the mind over 
the organs of special sense is for the time being sus- 
pended. Some consciousness is present, but it is not usually 
of sufficient intensity to leave much if any impression on 
the mind when the patient is awakened. 

There is generally present in hysteria more or less intense 



HYSTERIA. 181 

inclination to sleep, which may go on to lethargy, a con- 
dition which may last several days. This has been de- 
scribed as transient catalepsy. Several kinds of spas- 
modic manifestations most usually precede the state of 
somnolence. The pulse becomes small and intermittent ; 
the breathing is slow and in some cases scarcely to be 
detected. The skin is dry and cold ; the bladder loses the 
power to evacuate its contents, rendering necessary the use 
of the catheter. The bowels also lose their power to act, 
and may remain in this condition for weeks. The most 
powerful stimulation is needed to arouse the patient from 
this state for even a short time. 

At the termination of hysterical convulsions there is a 
somewhat similar condition of somnolence, but the fact 
that it is of short duration, and is followed by alleviation 
of the patient's symptoms, will serve to distinguish it 
from the state here described. 

The most unusual and severe form into which this 
hysterical somnolence may pass is the condition known as 
hysterical trance. The patient sees and hears, either per- 
fectly or in part, what is going on around her, but is un- 
able to move or to call out. 

There is a condition known as disease mimicry. We 
all remember our mothers' early warning that " mocking 
is catching." From automatic conditions this is a natural 
tendency. Mimicry of normal and abnormal conditions 
exists, an example being the suffering of sympathetic labor 
pains upon the part of husbands present during the parturi- 
tion of their wives, or their sufferings from the morning 
sickness of pregnancy. Francis Bacon speaks of this 
morning vomiting, and Dr. Weir Mitchell reports such a 
case. The treatment of hysteria may be divided into (1) 
psychical, (2) separation of the patient from her friends 



182 FUNCTIONAL NERVOUS DISORDERS. 

and usual surroundings, with such other moral treatment 
as may be deemed proper, and (3) medical treatment. In 
the last-named, the effort must be to combat the anaemia 
present by tonics and a large amount of meat in the diet. 
Massage and electrical baths with the static and inter- 
rupted current are also useful adjuncts. The moral treat- 
ment consists mainly in removing the patient from the 
pernicious influence of relatives and friends who, although 
meaning well, do harm. 

Functional diseases of the nervous system are in the 
great majority of cases due to malassimilation, as is the 
case with the organic diseases. In both acute and chronic 
cases the results obtained by treatment will depend upon 
the care which we bestow upon the digestive organs. In 
the physiological cure of disease the state of the digestive 
organs is the all-important factor; medicines may assist, 
but it is quite as probable that they often retard recovery* 



CHAPTER XX. 

HYSTERO-EPILEPSY. 

Hysteroepilepsy, according to Charcot and Richer, is 
only hysteria in the highest degree, and not hysteria com- 
plicated with other neuroses. Although hysteria in the 
male is not an extremely rare occurrence, still it is so fre- 
quent among females that it might be said to be the char- 
acteristic disease of that sex. I have seen one case of 
hystero-epilepsy in a lad, which came on from a fall and a 
great fright; and there are many physicians who have 
seen cases where the male patient imagines, or learns for 
the first time, that he has some fatal disease, or where, 
after some great physical or moral shock, he becomes as 
hysterical as a woman. 

In hystero-epilepsy there is the hysterically nervous con- 
stitution combined with the depressing effects of anaemia, 
prolonged anxiety, mental shock or excitement, and the 
stimulus of uterine and ovarian disturbance starting up 
the hysteric aura. In about all the functional diseases of 
the nervous system of women, the general condition is the 
same — the co-ordination and harmony of the cerebro-spinal 
and ganglionic nervous systems are sadly out of tune. It 
matters not what pulls the patient down, whether it is an 
exhausting menorrhagia or great mental anxiety, the re- 
sult is the same, and manifests itself often in these ex- 
plosions of weakness. 

183 



184 



FUNCTIONAL NERVOUS DISORDERS. 



The hystero-epileptic attack according to Richer is di- 
vided into four distinct periods : 

1. The epileptoid period. 

2. The period of contortions and great movements. 

3. The period of emotional attitudes. 

4. The period of delirium. 

The epileptoid period has a tonic phase, a clonic phase, 
and a phase of resolution. Loss of consciousness was com- 
plete during the entire epileptoid period in the following 
cases, as is the rule, and all the attacks were more or less 
complete. In speaking of the rarity of this disease, which 




Fig. 16. —First or Epileptoid Period. 

makes its study more interesting, Dr. S. Weir Mitchell 
writes " that in my experience, and it has been very great, 
these terrible cases are rare in America in any class of 
life, and most uncommon in the lower classes, among 
which Charcot seems to have found his worst and most 
interesting cases. In this disorder there is, I suspect, 
some difference between this country and Europe. " 

Dr. Charles K. Mills says that hystero-epilepsy of im- 
perfectly developed or irregular type is a not uncommon 
affection in this country, but the disease in its regular 



HYSTERO-EPILEPST. 



185 



type is comparatively rare. Dr. Allan McLane Hamilton 
Teports two cases. Hart and Barbour state that it is rare 
in Great Britain. They have seen one case in which it 
was present in a modified form. Many physicians whom 
I have met, both in Paris and New York, seem to believe 
that hystero-epilepsy is a Parisian disease, and rarely, if 
ever, met with elsewhere. I see no reason to think that it 
is any less common here than in France ; and it seems to 
me that physicians generally see these cases in their later 
stages, and after the most severe portion of the attack has 




</^w^M 



Fio. 17.— First or Epileptoid Period. Tonic Contractions. 

passed away, and then simply consider it as minor hysteria, 
and give it no thought. In the twelve cases which follow, 
and which have occurred in my practice, I have taken 
especial notice of the uterus and the menstrual function, 
believing that the ovary alone is not the only pelvic factor 
in producing the disease; in all of them, as in almost all 
previous cases reported, the uterus was diseased and 
menstruation abnormal. Dr. Charles Carroll Lee, in a 
short and valuable article on " The Relation of Peripheral 
Irritation to Diseases of the Womb and its Appendages," 



186 



FUNCTIONAL NERVOUS DISORDERS. 



advises general as well as local treatment, " for in all these 
cases there is feebleness of tone, often waste of tissue and 
marked hydremia, and a general tendency to nerve ex- 
haustion." He also states that "it is a striking clinical 
fact that mal-conditions of the uterus exercise far more 
influence in this direction than disease of the tubes or 
ovaries, however pronounced the latter maybe," and "that 
in neurotic conditions ablation of the uterine appendages 
is not only commonly useless, but often leaves the patient 
worse than she was before." Engelmann says "the uterus 




Fig. 18.— First or Epileptoid Period. Tetanic Attitude, Tonic Phase, of the 
Hystero-Epileptic Attack. 



is more liable to influence the system and determine the 
nerve reflexes than the ovary." There is nothing to show 
that the ovarian pain may not be symptomatic of uterine 
disease, seeing that the latter is present in such a large 
proportion of cases, and the ovaries and uterus are really, 
so to speak, only different parts of a single organ, although 
often treated as if there were no connection between them. 

Dr. Mills states as his conclusions: 

" In reference to oophorectomy for hystero-epilepsy, or 



HYSTERO-EPILEPSY. 



187 



any form of grave hysteria: (1) It is rarely justifiable ; 
(2) it is not justifiable in case of girls who have not men- 
struated; (3) when disease of the ovaries can be clearly 
made out by local objective signs, it is sometimes justifi- 
able ; (4) it is justifiable in some cases with violent nymph- 
omania ; (5) the operation is frequently performed without 
due consideration, and the statistics of the operation are 
peculiarly unreliable." 

Most hystero-epileptics are easily hypnotized or already 
in a hypnotic state, and the arrest of the attack by what 
Charcot calls ovarian . pressure is undoubtedly in many in- 




Fig. 19. —Second Period. Contortions. Arc of the Circle. 



stances through hypnotic suggestion, as his application of 
the hand is often very light and there is really no pressure 
to speak of. The ovarian pains are without doubt in many 
instances the sole cause of the attack. Charcot says: 

"Sometimes the pain is very severe, and the patients 
are unable to support the least touch, as the weight of the 
bedclothes, etc. . . . Add to that a certain degree of 
swelling of the abdomen, and you have the clinical en- 
semble of false peritonitis — the spurious peritonitis of Eng- 
lish physicians. ... At other times, the pain is not 



188 



FUNCTIONAL NERVOUS DISORDERS. 



spontaneously felt ; we are obliged to search for it by pres- 
sure, and it is found in the ovary, which is tumefied, and 
often the size of an olive or small egg. At this moment 
you can provoke the pain, which reveals itself with specific 
characters. It is not a common pain, but a complex sen- 
sation accompanied by either the whole or a part of the 
phenomena of the aura hysterica, the same as they produce 
themselves at the approach of a crisis, and this provoked 
sensation is recognized by the patients because they have 
felt it a hundred times. . . . We have provoked painful 




Fig. 20.— Second Period. Contortions. Arc of the Circle Incomplete. 



radiations toward the epigastrium, complicated sometimes 
with nausea and vomiting; then, if the pressure is con- 
tinued, soon come palpitations of the heart, with extreme 
frequency of the pulse, and at last it develops itself at the 
neck in the globus hystericus. . . . Certain cephalic 
troubles are evidently only the continuation of the same 
series of phenomena. Such are (if we speak, for example, 
of compression of the left ovary) intense whistlings in the 
left ear, which the patients compare to the strident whistle 
of a locomotive; a sensation of blows struck with a ham- 
mer on the left temporal region ; and, finally, a blurring 
of vision, marked especially in the left eye. The same 



HYSTERO-EPILEPSY. 



189 



phenomena would show themselves on the corresponding 
parts of the right side in case the compression should be 
made on the right ovary." 

Authors have distinguished two principal forms of 
hystero-epilepsy. In the first, hystero- epilepsy ivith dis- 
tinct crises, the convulsive accidents are of two kinds. 
They show sometimes the paroxysm of hysteria, sometimes 
the paroxysm of epilepsy, with the characters which are 
proper to each, and always perfectly distinct. In the 
second, hystero-epilepsy ivith combined crises, the con- 
vulsions in the very same attack are invested successively 




Fig. 21.— Second Period. Contortions. Variety of Arc of the Circle. 



with the appearance of hysteria and of epilepsy ; there ap- 
pears to be a melange of the two neuroses. 

It is with this last form that we are especially concerned 
here, the form that Louyer-Villermay, Tissot, Dubois 
(d' Amiens) , Sandras, Briquet, and Charcot considered as 
a grave variety of hysteria, in which the convulsions are 
of an epileptic character, as occurs in many other affec- 
tions of the nervous system, with the property of an ac- 
cessory element, and without changing anything of the 
nature of the primitive malady (Charcot). It is the 



190 FUNCTIONAL NERVOUS DISORDERS. 

epileptiform hysteria of Louyer-Villermay, of Tissot; the 
hysteria with mixed attacks of Briquet, and major or 
grand hysteria, as it is designated by M. Charcot. . . . 
A parallel between Richer's description of hystero-epilepsy 
or major hysteria and that which the authors give of minor 
hysteria shows the intimate connection existing between 
the two forms, the minor hysteria being considered as an 
attenuation of the major, in fact, the rudimentary form. 
The varieties of major hysteria are the results of modifica- 
tions of the symptoms which already exist; therefore we 
have the epileptoid attack, the contortion or demoniacal 
attack, the attack of ecstasy, and the attack of delirium. 

There are also varieties which result from the com- 
bination of phenomena habitually foreign to the attack — 
whence come the attacks of lethargy, attacks of catalepsy, 
and attacks of somnambulism. This first class receives 
some new light from Richer's studies on hypnotism and 
shows the near relationship which exists between hypno- 
tism and major hysteria. 

To the varieties of the major attack which have just 
been pointed out Richer has added also the three follow- 
ing: Attack of syncope, attack of spasm, attack of con- 
tracture. The attack of spasm belongs to the prodromic 
period, while the attack of contracture is classed among 
the varieties belonging to the fourth period. 

Prodromic Period. — The attack of major hysteria 
never comes as a surprise ; it is always preceded, as Richer 
says, sometimes during many days, by a train of phe- 
nomena which permits the invalid to foresee long before- 
hand the moment when she will fall in the attack. These 
signs are many and various ; they betray the disorder of 
the whole system, and we can say that none of the im- 
portant organs is exempt. 



HTSTERO-EPILEPSY. 191 

Richer arranges the prodromes under the following 
heads : 

1. Disorders of the mind; hallucinations. 

2. Disorders of the organic functions. 

3. Disorders of motility. 

4. Disorders of sensibility. 

He says : " The mental troubles are the first to appear, 
and come on sometimes eight days before the attack. The 
invalid herself is aware of a change in her mind; she is 
incapable of working with the diligence required; she 
neglects her habitual occupations, and has no pleasure in 
her usual amusements. Past impressions and recollec- 
tions, especially if painful, come crowding to her mind; 
she has no power to throw them off. Anything of a dis- 
agreeable nature affects her acutely, and the most insignif- 
icant trifles assume in her eyes an exaggerated importance. 
Occasionally she falls into a condition of profound melan- 
cholia that may reach a state of complete despair. 

Those in close attendance upon the patient can readily 
foresee the impending attack. Her external appearance 
betrays the mental trouble by a neglect of the niceties of 
the toilet and even of cleanliness ; the hair is dishevelled ; 
the face is emaciated; the patient is absorbed in never- 
ending reflections and meditations; she gazes fixedly into 
space, while now and then the changing expression betrays 
the presence of hallucinations. These attacks of depres- 
sion or melancholia alternate with moments of foolish 
gayety the cause of which is quite incomprehensible. The 
patient indulges in all manner of childishness, a mere 
nothing sufficing to send her into fits of long-continued 
laughter. The emotions are at the same time exalted or 
perverted. The patient is anxious, suspicious, and very 
irritable. She cannot bear the least contradiction, and no 



192 FUNCTIONAL NERVOUS DISORDERS. 

one, not even her best friends, has any influence over her. 
She becomes subject to sudden spasmodic attacks of af- 
fection or of hatred toward her companions. She will 
become either obstinately mute or exceedingly confidential. 
Very frequently she will appear to seek an occasion for 
dispute merely to satisfy a necessity for activity. She is. 
unable to keep still; there is a restlessness in all her limbs, 
and it is not rare to see her, in her excess of energy, turn 
against surrounding objects, overturning, breaking and 
ruining anything she finds under her hands. This agi- 
tation, accompanied by loud cries, gives her at times a 
dreadful aspect, but she is never so dangerous as are epi- 
leptics in their delirium. The impulse obeyed by the pa- 
tient is not an instinct of destruction to others, or to her- 
self ; it is an agitation that appears to have no other aim 
than that of making a noise and working off a surplus of 
activity. 

Richer still further says that hallucinations are frequent 
in hystero-epilepsy, and they may affect all the senses,. 
although they are especially apt to affect sight and hear 
ing. They often occupy an important place among the 
prodromes of major hysteria. The late M. Charcot held 
that there was a constant relation between the seat of 
hallucination and that of hemianesthesia. The most 
common hallucinations of sight are visions of animals: 
black cats, gray or various-colored rats, spiders, crows, 
vipers, etc., or of fabulous animals. M. Charcot was the 
first to show that these are not fixed visions. The animals 
appear to run always in a certain direction in front of the 
patient, either from left to right or the reverse, according 
as the seat of the hemiansesthesia is to the left or to the 
right. The anaesthetic side is always the point of depar- 
ture of the hallucinations ; the phantom as a rule comes 



HYSTERO-EPILEPSY. 193 

from behind and disappears in front. Scintillating stars 
and brilliant balls of light of different colors also appear 
before the patient's eyes. Richer asserts that hallucina- 
tions of hearing are no less common than those of sight. 
They affect principally the ear of the anaesthetic side. 
These hallucinations may all come on in the daytime, and 
torment the patients even when they are in the company 
of other people, but it is at night that they are the most 
intense. Then they are not so much a rapidly passing 
vision, as a prolonged drama in which the patient has her 
role to play. 

Nearly all of the patients are troubled with a whistling 
sound in the ears, especially in the ear of the anaesthetic 
side. They also hear the rolling of wagons, the striking 
of clocks, music of a band, the singing of birds, etc. 
The night hallucinations are often erotic in character, 
which shows that the genital tract is largely involved. 
Extreme fatigue follows a night of hallucinations, and is 
evinced by drawn features, pale faces, and dark circles 
around the eyes. Hallucinations occupy so important a 
place among the phenomena preceding the attack of hys- 
tero-epilepsy. that they sometimes form part of the aura 
and mark the beginning of a fit. 

Disorders of the Digestive Functions. — In chronologi- 
cal order the digestive disturbances are the first to appear 
among the prodromes of the attack, along with the cere- 
bral disorders of which we have spoken ; they usually pre- 
cede by some days the painful phenomena. They seem to 
be constant. Either the patient is without appetite, or 
else the taste is much perverted. The food eaten is often 
immediately rejected. Between meals nausea is some- 
times present, owing to the spasmodic contractions of the 

diaphragm, of the stomach, and of the oesophagus. This 
13 



194 FUNCTIONAL NERVOUS DISORDERS. 

may result in a prolonged and painful state of nausea. 
Spasm of the throat, that is to say, hysterical suffoca- 
tion, may occur in the pharynx, in the oesophagus, and in 
the upper part of the trachea (Briquet). 

If, says Briquet in his " Traite de l'Hysterie," we observe 
attentively what takes place when an hysterical woman 
experiences a moral emotion, we may easily grasp the 
reason of this neurosis. Out of four hundred hysterical 
patients he has found only thirty who had never been 
troubled with suffocation. This spasm of the throat, so 
common in hysteria, which may be met with during the 
attacks as well as in the intervals, is also observed among 
the prodromes of major hystero-epilepsy, and ordinarily 
forms a part of the painful phenomena of the aura hys- 
terica. Mention should be made here of the borboryg- 
mus and the tympanites which are present, and often 
severe. 

Disorders of the Secretions. — Ptyalism in varying 
degree is often present at the beginning of the attack, 
and plays its part in the production of the foam which 
comes to the lips in the epileptoid period. The urine is 
abundant, clear, and colorless (nervous urine). 

Disorders of Respiration. — The disorders of respira- 
tion, as a rule, consist in a more or less pronounced sense 
of oppression. The patients feel the need of breathing 
more air. But the spasm of the larynx is a part of the 
convulsive phenomena which occur during the days pre- 
ceding the attack, and the hiccough and the laughter 
belong to the same category. Hysterical yawnings also 
occur at this time. 

Disorders of Circulation. — Cardiac palpitations hold 
a prominent place among the prodromes of the hystero- 
epileptic attack. All patients complain of it. These pal- 



HYSTERO-EPILEPSY. 195 

pitations are at first infrequent, but return upon the slight- 
est occasion, or without any appreciable cause. At a later 
period they constantly accompany the painful phenom- 
ena of the hysterical aura. The palpitations are at 
times so intense as to be felt all over the chest, in the 
neck, and even in the temples. Vasomotor complications 
are not uncommon. Rosenthal cites an interesting case, in 
which the precursor of the attack was a feeling of cold, 
with discoloration of the hand and fingertips. In another 
case, resembling Rosenthal's, the patient's arms grew 
colder and bloodless, and were insensible to the pricks of a 
pin. The patient was at other times not anaesthetic. 

Disorders of Motility. — Hemianesthesia is considered 
a constant symptom of hystero epilepsy, and always ac- 
companies anaesthesia and disappears with it as well. 
When the attack is approaching, muscular weakness in- 
creases ; the patient will perhaps be unable to use her arm 
to comb her hair, and is unable to retain a grasp of objects 
with her hands. By the dynamometer, the right hand 
will register less than the left, the proportion being six to 
twenty-one. 

The walk is uncertain, the patients having a very un- 
steady gait. The leg of the anaesthetic side bends under 
its weight; oftentimes they have painful cramps, and 
marked tremulousness. The condition of the limb per- 
mits exaggerated reflex movement of the patella. 

Similar to the tremor of true epilepsy is that which oc- 
casionally troubles these patients. It consists of a sudden 
tetanoid state of a group of muscles of short duration, end- 
ing as suddenly as it started, thus resulting in a rapid 
movement of the levers from which the tendons of the 
muscles take their origin. This movement may be com- 
pared to that produced by a discharge of electricity. 



196 FUNCTIONAL NERVOUS DISORDERS. 

This tremor will at one time be limited to one side of 
the body, a limb, the face, the abdomen, etc., of the anaes- 
thetic side being selected, and then again the whole body 
may be affected. When the patient walks, she is liable to 
fall ; when sitting, she is apt to be suddenly lifted from her 
seat, only to fall again heavily. The attacks are most 
apt to occur at night, at the approach of sleep, but they 
may also come on in the daytime. At night she may 
be suddenly awakened with the feeling that she is fall- 
ing out of bed, and indeed at times this actually takes 
place. 

During the prodromal period, the tremblings are similar 
to those at the beginning of an epileptiform convulsion, 
and during the. few seconds preceding the crisis they occur 
more and more rapidly, until they become absolutely con- 
tinuous, and epileptic tetany ushers in the attack. 

Contracture is frequently a precursory phenomenon of 
the crisis. It is usually partial and comes on suddenly. 
It travels from one part of the body to another until all 
the extremities are involved, shortly before the beginning 
of the attack. The contracted limbs vary greatly as to 
position, but are sometimes affected in an invariable man- 
ner in some one particular patient. Richer considers that 
the contractures should be classed with the symptoms 
which precede the major attacks, while the tremblings be- 
long to such of the minor attacks as in some particulars 
resemble the major ones. 

Disorders of Sensation. — Anaesthesia, or more often 
hemi-anaesthesia, is a symptom of hystero-epilepsy in the 
interval between the attacks. It may be incomplete; for 
instance, the prick of a pin will be felt but will convey no 
sensation of pain, analgesia being present. A few days 
previous to the attack, anaesthesia comes on, if not already 



HTSTERO-EPILEPSY. 197 

present, and takes the place of the analgesia. In time it 
becomes fixed, but disappears temporarily in the intervals 
of attacks. Hyperaesthesia localized in certain nerve 
areas is not rare in hysterical patients, and is frequently 
found among the prodromes of an attack. An example of 
this may be seen in Rosenthal's case, already mentioned, 
but we note that in the days preceding the attack it is re- 
placed by anaesthesia. 

Special sensation is also affected, on the same side as 
general sensibility. Both are equally affected by the same 
agents. This does not mean that the one cannot exist 
without the other. Cutaneous anaesthesia may exist with- 
out involving the special senses, although it rarely does. 
Anaesthesia, likewise, may affect some special sense, with- 
out involving the skin. 

The power to distinguish colors is completely lost, and 
dyschromatopsy becomes achromatopsy. Even amblyopia 
may be well marked. 

The Hysterical Aura. — The real attack is preceded by 
the prodromata mentioned; Charcot thus describes the 
onset of the convulsions. 

" (1) At first there is pronounced and intense pain ; the 
patients complain of the weight of the bedclothes and 
cannot even bear to be touched ; they shrink instinctively 
from the examining finger. The abdomen is so swollen as 
to present a perfect clinical picture of spurious peritonitis, 
in connection with the sensitiveness alluded to. Muscles 
and skin both lend themselves to the delusion. (2) In 
another instance the pain will only be aroused by pressure, 
and then it will be noticed that (a) the skin is totally 
anaesthetic; (b) the muscles, if relaxed, may be pinched 
and stretched without causing pain ; (c) the seat of pain 
being found to be neither in the skin nor in the muscles, 



198 FUNCTIONAL NERVOUS DISORDERS. 

we must pursue the examination a little further, and dis- 
cover it by making deep pressure into the abdomen." 

There is no doubt that the seat of pain is invariably in 
one place, and indeed the patients themselves will always 
locate it there. If a horizontal line be drawn from one 
anterior superior spine of the ilium to the other, and upon 
it be let fall the perpendicular lines that form the lateral 
boundary of the epigastrium, at the intersection of the 
horizontal and perpendicular lines will be found the spot 
which is the seat of pain, as is proved by its sensitiveness 
to the touch. 

By deep exploration of this region, we can clearly feel 
the portion of the inlet which describes an internally con- 
cave curve. At about the centre of this curve we usually 
find an ovoid body which is placed transversely, and which 
slips from under the fingers when pressed against the bony 
wall. If this body be at all inflamed, which is frequently 
the case, it will be of the size of an olive, or even of a 
small egg. With a little practice it will be possible to 
feel it, even when it is not enlarged. It is at this point in 
the exploration that the pain is caused, which is severe in 
its nature, and accompanied by all or some of the phe- 
nomena of an hysterical aura, such as occurs previously 
to an attack. 

The birthplace of the aura has thus been found by the 
exploration, which has also caused pain in the region of 
the epigastrium, complicated at times by nausea and vom- 
iting. If pressure be continued, palpitation of the heart 
will be caused, with corresponding rapidity of the pulse, 
and presently the globus hystericus will make its appear- 
ance in the throat. 

Disturbances in the head are apt to come on about this 
time. For instance, if the left ovary be compressed, a 



1, 1'. 


Supra-Mammary Zones 


2. 


Mammary Zones 


3, 3'. 


Sub- Axillary Zones 


4,4', 5. 


Sub-Mammary Zones 


6,6'. 


Costal Zones 


7, 7'. 


Iliac Zones 


8,8'. 


Ovarian Zones 




PRINCIPAL HYSTEROGENIC ZONES 

ANTERIOR ASPECT OF THE BODY 



To face p. 199. 



HTSTERO-EPILEPSY. 199 

sound compared by the patient to the noise of a steam 
whistle will be heard in the left ear; hammerings are felt 
on the left temporal region, and an indistinctness of vision 
is noticed in the left eye. The same thing would occur in 
the right eye were pressure to be made on the right ovary. 

Investigation cannot well be carried beyond this point, 
for consciousness begins to be affected, and the patient can 
no longer give an account of her sensations. Further 
pressure and exploration would cause the immediate ap- 
pearance of the crisis. 

At the approach of an attack, ovarian pain is increased 
and all the painful phenomena of the h3 r sterical aura de- 
velop spontaneously. At first they are infrequent and 
slight in degree, but gradually increase in frequency at 
the approach of the attack. 

Hystero- Genetic Zones. — We have seen that an attack 
may be brought on by pressure upon a painful ovary. 
That is evidently the starting-point of the hysterical aura, 
and a gentle touch suffices to call forth all the painful phe- 
nomena which make up that aura. If the irritation be 
somewhat prolonged, a major attack will be brought on. 
Later we shall see that the same method used to cause an 
attack will also stop it. 

The ovarian region is, however, not the only one whose 
irritation will bring on or arrest the convulsions. The 
hystero-genetic zones have a constant relation to hemi- 
anaesthesia. Although we know that the ovaritis exists 
on the anaesthetic side, yet several cases are known where 
the ovaritis was on the side opposite to the anaesthesia. 
Sometimes the zone is on the median line. Gaube has 
observed hystero-genetic zones upon the limbs, a condition 
not seen by Charcot in any of his patients. 

These zones are usually situated at or very near to the 



200 FUNCTIONAL NERVOUS DISORDERS. 

articulations. We find them in the hand, the elbow, the 
groin, in the popliteal space, and at the ankle. It is no- 
ticeable that they are on the side of flexion. Gaube found 
that when the zone existed in a limb, compression of the 
nerve trunk of that limb brought on an attack similar to 
that caused by pressure upon the zone itself. He found 
that the mammary gland is a hystero-genetic zone for the 
viscera. Pressure, not pinching, must be used in this 
situation, to bring on a convulsion. 

He has found that these zones are more often seen on 
the anterior than on the posterior portions of the body 
and limbs, and that when they are anterior they are apt 
to incline to the iateral portions and to be often double 
and symmetrical. When on the posterior parts, they are 
usually single and in the median line, and oftener on the 
left side than on the right. According to both Richer 
and Gaube, the unilateral zones are more apt to be on the 
left side. These zones are not always in the same con- 
dition of excitability, but are more easily excited when an 
attack is near. Their sensitiveness may be diminished by 
the application of a mustard paste, the production of local 
ansemia (Esmarch's bandage), hypodermic injections of 
water, and local electricity with the continuous or the 
interrupted current. Metals and wood have the same re- 
sult, and during etherization the same thing occurs. The 
ascending or descending medullary currents, the cerebral 
currents, cause the disappearance of the zones, and loss of 
excitability of the nerve trunks which inhibit them. 

It is an undeniable but unexplained fact that while one 
irritation of a zone will bring on convulsions, a second 
irritation will stop them ; but while a mere touch will serve 
to bring on the attack, deeper pressure is needed to arrest 
it. When a patient has more than one hystero-genetic 




Dorsal Superior Zone 

2. Dorsal Inferior Zone 

3. Lateral Posterior Zone 



PRINCIPAL HYSTEROGENIC ZONES 



POSTERIOR ASPECT 



To face p. 200. 



HYSTERO-EPILEPSY. 201 

zone, the attack caused by the irritation of one may be 
brought to an end by pressure upon another. 

We are indebted to Paul Richer for most of the preced- 
ing facts relating to the prodromal symptoms of hystero- 
epilepsy. No one else has given the subject such careful 
study as he. Many of the phenomena are undoubtedly 
rare, but they are certainly interesting, and it is to him 
that all credit is due for clearing up this obscure subject. 

Dr. Arthur Gamgee, in the British Medical Journal 
for October 12th, 1878, gives an excellent description of an 
hystero-epileptic attack which he witnessed in one of Dr. 
Charcot's wards at the Salpetriere. There were also 
present, among others, Drs. Yirchow, Ernest Hart, Os- 
car Liebreich, and Stewart Turner. He speaks of the 
inhibition of the attack by pressure in the ovarian region. 
When I tried this manoeuvre it seemed to make the pa- 
tients worse than before ; many were unable to bear severe 
pressure. The following is from Dr. Gamgee's article. 

" The patient, a young woman of considerable vigor and 
intelligence, is apparently about 22 years of age, and is 
very frequently subject to the most characteristic hystero- 
epileptic attacks. These attacks had been exceedingly 
frequent on the day preceding our visit, but had been 
inhibited by the systematic application of pressure to the 
right ovarian region, as will be more particularly men- 
tioned in the sequel. They still continued to recur. 

" Professor Charcot pointed out that the hystero-epileptic 
seizure, besides occurring spontaneously, can usually be 
induced with ease by some modes of peripheral irritation. 
In the present case for instance, by suddenly 'gripping' 
the skin of the breast on both sides, about on a level with 
the fifth rib and midway between the anterior and pos- 
terior boundaries of the axilla, the patient instantly fell 
into the hystero-epileptic convulsion. The constancy with 



202 



FUNCTIONAL NERVOUS DISORDERS. 



which the effect followed the cause was demonstrated over 
and over again to be absolute. 

" Although the various phenomena of the hystero-epilep- 
tic seizure are known to many readers through the writ- 
ings of M. Charcot, it may not be uninteresting to describe 
them with all minuteness as they were presented before us 
by this patient. The attack may be conveniently divided 
into three or four stages. 

" The first stage followed the application of the periph- 
eral irritation without the intervention of any perceptible 
latent period ; its features were the following : The head 




Fig. 22.— Second Period. The Violence of the Great Movements. 

was thrown violently backward, the limbs and body be- 
came rigid, the respirations infrequent and stertorous ; in 
a few seconds the tonic spasms were succeeded by clonic 
spasms affecting the muscular system. A slight remis- 
sion lasting for a very few seconds occurred, which was 
spoken of as a kind of entr'acte, and then commenced 
the second stage. The first may be termed the epilepti- 
form stage. 

" The second stage was characterized by extraordinary 
movements affecting the whole trunk. The back being 
somewhat opisthotonically arched, the body was thrown 
with great violence and astounding rapidity alternately on 



HYSTERO-EPILEPSY. 



203 



to the occiput and heels. This stage, which, like the first, 
is of very brief duration, is denominated the phase cles 
grands mouvements ; during its continuance occur the first 
hallucinations, to be afterward referred to. The violent 
movements cease almost instantaneously and then follows : 
" The third stage or stage of emotional attitudes (phase 




Fig. 23.— Second Period. Contortions. Demoniacal Attack. 



des attitudes passionelles) . During this stage the pa- 
tient assumes successively the expression of face, the atti- 
tudes, and the gestures which portray varied emotions — in- 
tense and vivid. The varied emotional states will be dis- 
tinguished by letters in the order in which they occurred. 

"a. No sooner had the great movements ceased, than 
raising herself into a sitting posture, with clenched fists 



204 FUNCTIONAL NERVOUS DISORDERS. 

and menacing expression, the patient presented the most 
startling picture of one threatening ; but almost instantly 
the picture changed to 

" b. The whole expression and attitude portrayed cower- 
ing, a,bject fear. Of no longer duration than a, b was 
followed by stage 

" c. The patient now assumed an expression of absolute 
beatitude. It is impossible to describe the look of saintly 
happiness, as of one who realized the blessedness of heaven, 
which the patient presented. It was the expression which 
some of the old masters have impressed upon the saints 
and martyrs. 

"But now occurred a change no less striking than the 
preceding. 

" d. The expression of saintly happiness was succeeded by 
one of intense joy ; the patient sees one whom she loves ; she 
beckons to him to come, to come quickly ; he has come. . . . 
Then succeed gestures which stamp this as the phase of 
lubricity, or the stage of the emotional attitudes. 

" e. Again fear takes possession of the patient ; at first 
it is rats which she sees and which she appears to fear 
the attack of, which evoke passionate exclamations of 
dread and disgust ; then it is obviously the fear of some 
human being which oppresses her and causes her to beg 
for mercy. 

"/. There is no longer fear. The patient hears the 
strains of music ; she is pleased ; she herself begins to hum 
the tune, but only for an instant, for 

" g. Her singing is followed by weeping, which is broken 
by reproaches addressed to her parents as the cause of her 
misery. This last phase (g) in the stage of passionate at- 
titudes may be made to constitute a fourth stage or a stage 
of recovery, in which hallucinations persist for a time." 

The following table will illustrate the dependency of 
this grave neurosis upon depressed conditions of the ner- 
vous system, resulting from overwork and worry, com- 
bined with local uterine or ovarian or digestive disorder. 



HYSTERO-EPILEPSY. 



205 






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HYSTERO-EPILEPST. 207 

The following extremely severe case of hystero-epilepsy 
is well worth recording, on account of its many typical 
features. The particular circumstance in this case to 
which I would call attention is the fact that the severity 
of the attack was not at all diminished, but, on the con- 
trary, very markedly increased by pressure on the right 
ovarian region. This is contrary to Charcot's experience 
in many of his cases, and was probably the result of the 
marked inflammatory condition here present. 

Case I. — Hystero-Epilepsy ; Right Ovarian Hyper- 
cesthesia, Much Delirium, Severe Pelvic Inflamma- 
tion, Dysmenorrhea ivith Cervical Stenosis, Resulting 
from Criminal Abortion. — Mrs. R., aged 26, blonde, 
divorced. She was first seen in Januar}-, 1885. She suf- 
fers much mental distress on account of separation from 
her husband. She has been ill for two years with dys- 
menorrhoea dating from a criminal abortion. She was 
under treatment in the country, and her physician told 
her that she had a small tumor of the right ovary, and 
also a pelvic abscess. On examination, I find marked 
stenosis of the cervical canal a half-inch from the external 
os, with great tenderness on the right side of the uterus. 
When I first saw this patient she was in the second 
period of the attack, that of contortions and great move- 
ments, with marked opisthotonos. While pressing over 
the region of the right ovary to inhibit the attack, she 
screamed forme to press harder. The nurse and I pressed 
with all our strength, but it did not seem to give her 
much if any relief from the terrible pain. During the 
period of delirium, she has the hallucination that she sees 
her husband, and begs and entreats him to come to her 
(repeating constantly, "Oh come, George, do come," and 
finally crying out in the deepest anguish, "Oh, George, 
why do you not come?"), the expression on her face in- 
dicating the emotion of piteous supplication. She had 
hemianesthesia, but not quite complete, of the right side, 



208 



FUNCTIONAL NERVOUS DISORDERS. 




HYSTERO-EPILEPSY. 209 

with a feeling of numbness and severe pain at times from 
the knee to above the hip; right hand and foot cold, with 
partial hemiplegia; she complained of great and constant 
pain in the top of the head. She expressed it, "as if the 
crown was raised up and came down with a crash." After 
the attack, there are constant throbbing and cutting pains 
in the pelvic abdomen, and over the region of the right 
ovary there is tenderness. She feels at times feverish, and 
then cold with clammy perspirations. There is spinal 
tenderness from the level of the angles of the scapulae to 
the sacrum, and she has throbbings and twitchings through 
the whole right side, even to the fingers and toes. The 
right arm aches, and there is numbness in the right side 
all the time. No trouble on the left side, except pain over 
the region of the heart after a deep inspiration. Appetite 
poor, tongue heavily coated, and breath foetid. I gave her 
bromide of potassium and the elixir of the valerianate of 
ammonia in large doses, with injections of asafoetida dur- 
ing the attack, with no benefit. I afterward made a slight 
dilatation of the cervical canal with my steel dilator and 
applications of the faradic current to the right side 
without any improvement. 

The very peculiar hallucinations experienced by the 
patient in the following case are of interest. The case is 
one of characteristic hystero-epilepsy, but there is partial 
consciousness during the period of the grand movements. 

Case II. — Hystero- Epilepsy j Right Ovarian Hyper- 
cesthesia, Much Delirium, Dysmenorrhosa, Constant 
Leucorrhcea, Lacerated Perineum, Two Abortions. — 
Mrs. B. age 44, has had six children and two miscar- 
riages. She has a cousin who is a cataleptic. Ten years 
ago she had a sunstroke, and " since then has been feeling- 
miserable." She works hard, and is burdened with a 
shiftless husband, who causes her a great deal of anxiety. 
For a week before.the attack, which always comes on just 
as the menstrual flow begins, there are prodromes — she has 
14 



210 FUNCTIONAL NERVOUS DISORDERS. 

dull headaches, is irritable and nervous, has great thirst, 
and her feet are icy cold. Two days before the menstrual 
period her head feels queer. There is also palpitation of 
the heart. She has hallucinations, imagines that any ob- 
ject seen is of enormous size — as, for instance, a chair — and 
wonders if she could ever walk around it. During the 
attack she has a dull, heavy pain in the right ovarian region 
and down the thighs, and a terrible pain at the base of the 
brain. During the stage of contractions, there is slight 
opisthotonos, and after the clonic grand movements her 
strength leaves her, she is completely exhausted and 
drops into a deep sleep. There is partial consciousness 
during the stage of grand movements. She can tell that 
there " are people around, her, and that something is mov- 
ing." In this stage, she casts herself all over the bed, and 
struggles frightfully. She has been under treatment by 
several physicians, and says the only thing that gives her 
the slightest relief is ordinary bottled sodawater. She is 
weak, and has leucorrhoea. On examination, I find the 
uterus tender, but of normal size and position. There is 
tenderness in both ovarian regions, greatest on the right 
side, and a cellulitic deposit behind the uterus. She has 
endometritis and a lacerated perineum. In some of her 
attacks there is demoniacal fury; in one she drove her 
son and daughter from the house. 

In the case of the following patient, as in all other suf- 
ferers from this disorder, the condition is a cerebro-spinal 
neurosis — here especially apparent — and the hysterical ele- 
ment is particularly well marked. As in the other cases 
recorded, there are many points of extreme interest — the 
spinal irritation, the pains in the head during delivery, 
the bronchial hystero-neurosis, and hysterical attacks fol- 
lowing the slightest excitement. 

Case III. — Hy stero- Epilepsy ; Ovarian Hypercesthe- 
sia, a Bronchial Hystero-Neurosis, Dysmenorrhea, 
Two or Three Abortions. — Mrs. B., divorced woman, age 



HYSTERO-EPILEPSY. 211 

38, has had five children and two abortions. She has had 
attacks since her second child was born in 1878. During 
the labor, which was brought on at eight months by fright, 
all the pains "were in her head," and she was unconscious 
until after delivery. The attack comes on with globus 
hystericus, followed by a sinking sensation and uncon- 
sciousness. I first saw this patient in February, 1885. 
She was taken with an attack at the dining-table from the 
excitement of an unpleasant interview with her sister. In 
the first or epileptic stage, she stiffened in her chair with 
her extremities extended, thumbs flexed tightly on the 
palms of her hands, jaws firmly set, and eyes closed; 
clonic spasms succeeded, and were followed by the stage 
of resolution. She has spinal irritation from occiput to 
coccyx, and the least excitement brings on pain in the back 
of the head. She used to have " cramps" during menstrua- 
tion, which were always profuse, lasting usually six or 
seven days. Just before menstruating, she always has 
pains in the head and "a real bad cough" — a bronchial hys- 
tero-neurosis. She is hysterical from the least excitement. 

In the next case, as with the generality of divorced 
women, as well as in those who have departed from the 
paths of virtue, the resulting worry and mental depression 
were exciting causes of the attack. The complication of 
somnambulism is here specially noteworthy. 

Case IV. — Hystero-Epilepsy j Ovarian Hyperesthe- 
sia on Both Sides, Somnambulism, Dysmenorrhoea, Five 
Abortions. — Mrs. 1ST., age 42, a tall robust brunette, di- 
vorced. She has had five children and five abortions; 
but has not been pregnant since the birth of her last child, 
who is now 15 years old. All deliveries have been instru- 
mental from pelvic deformity. She says that with each 
of her last three labors she had an attack, and the child 
was born while she was unconscious. The last child was 
born while she was in the opisthotonic position. Her first 
attack was at the birth of her third child, it being a second 



212 FUNCTIONAL NERVOUS DISORDERS. 

confinement in twelve months ; at this time she was slight 
and very weak. The attack came on from extreme mental 
excitement and worry, caused by trouble with her husband. 
Has prodromes, consisting of faint feelings^ a queer sensa- 
tion in the head, flushing of the face, and gradual uncon- 
sciousness. The attack comes on a day before menstrua- 
tion, and on the second day of terrible pain she experiences 
relief on the appearance of the flow which is always pro- 
fuse. She is always very much depressed and downhearted 
before and after the attack. She has broken some of her 
teeth in the tetanic contractions of the epileptoid period. 
She is much prostrated after it and remains in bed for a 
week. There are no hystero-genetic zones or painful spots 
except over both ovarian regions. After the attack she 
has hallucinations, also achromatopsia and amblyopia. 
During some of the attacks she has somnambulism, walks 
around the street in her nightclothes, and has to be led 
home. 

The predominance of the stage of delirium and maniacal 
excitement from the sudden arrest of the menses and the 
severe pain resulting are prominent points in the follow- 
ing case. Severe gastralgia, due to uterine disease, is a 
common exciting cause of hystero-epilepsy. This case is 
very similar to many reported from La Salpetriere. 

Case V. — Hystero- Epilepsy ; Ovarian Hyperesthe- 
sia, Period of Delirium Predominating, Dysmenor- 
rhoea, Sudden Suppression of Menses, Endocervicitis, 
Two Abortions. — Mrs. B., age 24, is of lively disposition, 
and has been six years married. She first menstruated at 14 ; 
has one child aged 5 years ; has had two criminal abortions, 
the last three years ago, and since that time she has had, 
at every third or fourth menstrual period, severe "cramps" 
in the epigastrium, and they grow worse each time. On 
July 4th, 1887, the second day of her menstrual period, 
she caught cold by stepping with her bare feet on an oil- 
cloth after getting out of bed. This arrested the menstrual 



HYSTERO-EPILEPSY. 



213 




Fig. 25.— Fourth or Period of Delirium. 



214 FUNCTIONAL NERVOUS DISORDERS. 

flow, and at eleven o'clock p.m. the attack came on with 
grinding of the teeth from the severe pain in the epigas- 
trium, and with contractions of the muscles of the neck. 
There was wild delirium, it requiring three or four per- 
sons to hold her. In her demoniacal rage, she tore her 
clothes to rags, imagined that she was on the elevated or 
cable roads, was snow-balling, or, the next moment, swim- 
ming in the surf. She fondled a pillow for her child, and 
rushed about the room striking herself against objects with 
great force. I gave her one- third of a grain of morphine 
by hypodermic injection, and she gradually became calm, 
recognized her surroundings, and fell asleep. These at- 
tacks last nearly three hours. She was weak and ex- 
hausted for some days following. She was too sore and 
tender over the ovarian regions, particularly the right, to 
admit of any pressure. There was extreme pain in the 
epigastrium (which was swollen) and under the angles of 
both scapulse; also cervical endometritis. 

Heredity is an important element, sometimes two or 
more of the same family having the disease. 

Case VI. — Hystero- Epilepsy ; Ovarian Hyperesthe- 
sia, Nullipara, Overwork and Anxiety, Severe 
Menorrhagia. — Mrs. D., age 30, is a cousin of Miss B. of 
Case VIII. ; by occupation she is a dressmaker, and is a 
tall, well-formed, handsome brunette, with a nervous 
manner. She has another cousin who is an epileptic. 
Five years ago had her first attack, brought on by mental 
excitement, while sitting in a warm room, followed by two 
more in rapid succession. August 16th, 1888, while in a 
drug store waiting for some medicine, she had an attack 
from the excitement of seeing Miss B. in her paroxysms. 
It came while she was sitting in a chair, and as conscious- 
ness returned she had a recollection of the clonic con- 
vulsive movements of her hands and right foot. The 
attack is preceded by heart palpitation and hysterical 
suffocation, and is immediately followed by unconscious- 
ness. The different stages in this case are similar in every 



HYSTERO-EPILEPSY. 215 

respect to those of her cousin's case. Her menses occur 
every two or three weeks, are painless and profuse, lasting- 
seven to eight days. She complains of pains in the small 
of the back ; her bowels are regular, and she passes large 
quantities of dark, heavy urine free from albumin. When- 
ever she is excited she is afraid of an attack. Her father 
had several attacks of very severe epistaxis, and finally 
died of cerebral hemorrhage. A brother has lately died of 
phthisis, and another brother, as well as herself, frequently 
has attacks of bronchitis. 

That somnambulism and catalepsy are often part of the 
attack is well exemplified in the following case. We 
may also note the great number of attacks in a single day 
(eighteen) and the hypersensitiveness of the nervous sys- 
tem, the heart palpitating upon the slightest exertion. 

Case VII. — Hy stero- Epilepsy ; Left Ovarian Hyper- 
cesthesia, Trance or Cataleptoid State, Somnambulism, 
Dysmenorrhoea, Slight Flow, Constant Leucorrhoea. — 
Mrs. R., age 23, had her first attack at 17, from fright. 
She has always worked hard. At 20, she had an attack 
from inhaling gas for extraction of a tooth. She says 
that on one very warm day she had eighteen attacks, and 
that it required several people to hold her. She is preg- 
nant for the first time, and fright from the quickening 
gave her an attack. Her head has a tight, compressed 
feeling; there is no outcry nor frothing at the mouth; she 
falls and stiffens, or, if in a chair, slides to the floor feet 
first. She is opisthotonic during attack, consciousness 
being lost for fifteen or twenty minutes, is then dizzy and 
sometimes vomits. She often has prodromes for an hour 
before the attack — is hysterica], feels oppression of breath- 
ing and headache at the vertex ; at other times no notice 
is given. The heart palpitates upon the slightest exertion. 
When younger, she had severe leucorrhoea before men- 
struating and pain in the small of the back. She is very 
weak; the menstrual flow is scanty, but she has had 



216 FUNCTIONAL NERVOUS DISORDERS. 

vicarious flow from the nose. Seven }-ears ago she had 
"brain fever" caused by overstudy (?) and her mother's 
death, was four months in bed, and frequently delirious 
and maniacal. In the attack, during the period of de- 
lirium, she imagines that others are trying to do her bodily 
harm. She is a somnambulist, but is usually detected im- 
mediately upon rising or after a short walk. She is also 
hystero-cataleptic, the condition al ways coming on at night 
in bed ; she has a sensation of smothering, and can neither 
answer nor move when spoken to. She has had these 
cataleptic attacks nearly every night for a week. The 
pain is in the left ovarian region. She has malarial symp- 
toms, chills, fever, perspiration, and drowsiness. 

The ophthalmic hystero-neurosis, amblyopia of the left 
eye, being a reflex phenomenon from left ovarian irrita- 
tion, is interesting (see plate). Indeed, almost everything 
connected with these cases is remarkable and of interest. 
In a much milder form it is not uncommon. Abdominal 
pressure in such cases increases the severity of the attacks. 
The majority of these patients are very melancholic. 

Case VIII. — Hy stero- Epilepsy ; Hystero- Catalepsy 
and Ecstasy, Left Ovarian Hypercesthesia, Cutaneous 
Anaesthesia, Amblyopia of Left Eye an Ophthalmic 
Hystero - Neurosis, Dysmenorrhcea, Irregular and 
Scanty Flow, Continuous and Severe Leucorrhcea. — 
Miss B., age 21, is a tall, well-nourished blonde. Her 
parents are dead — father from cancer, mother from 
nephritis, and she lives with her brothers, who abuse her 
and are a source of constant anxiety. For a year has 
had pain and swelling over the left ovary, pain being 
severe in character and of short duration. At times her 
feet swell at the insteps. She urinates but seldom and 
onty in small amounts ; the urine contains no albumin; she 
has severe unilateral, migrainous headaches, left side and 
left eye, every other day. Menstruation is irregular, scanty, 



HYSTERO-EPILEPSY. 217 

and painful. Her first attack was two weeks before I saw 
her. She falls, becomes unconscious, and convulsion fol- 
lows. The attack comes on with sobbing, hysterical suffo- 
cation, and palpitation of the heart. There is a state of 
tonic contraction of the muscles, which is followed by 
opisthotonos. After a little the right leg is thrown vio- 
lently over the left in the air, and the stage of resolution 
gradually supervenes. She then lies in an exhausted con- 
dition, and finally goes into a heavy sleep. I saw this 
patient again the day following another attack, and found 
her ecstatic in the position of " crucifiement" with eyes 
looking upward, in a condition of hystero-catalepsy. She 
was totally unconscious during the attack, her skin was 
cold and colorless, and her pulse weak. After her second 
attack there was partial loss of sensation in her lower 
extremities. Her abdomen was very sensitive to pressure, 
and she was threatened with an attack when pressure was 
continued. I saw her two years after; she had had no 
return, but she says that ever since the attacks she is 
afraid of herself in the horsecars. Leucorrhcea is severe 
and continuous. 

Severe pains at menstruation are probably among the 
most common causes of hystero-epilepsy, as they are pres- 
ent in a great number of cases, and seem often to be the 
sole cause of the attack. 

Case IX. — Hy stero- Epilepsy ; Ovarian Hyperesthe- 
sia, Much Delirium, Dysmenorrhea, Irregular and 
Scanty Flow. — Miss S., age 18, is single, rather plump, 
emotional. Her father died from phthisis ; her mother suf- 
fers with neuralgia and is very melancholic. While visit- 
ing in the house of Case II., she was taken with an attack 
while sitting in a chair. Her friends first noticed a pecu- 
liar expression upon her face, and immediately after she 
was seized there was abdominal pain followed by the dif- 
ferent phases of the hystero-epileptic attack. During the 
stage of delirium she screamed piteously for her dead 



218 FUNCTIONAL NERVOUS DISORDERS. 

father to come and take her home. She slept all the next 
day, and while returning home that evening was taken 
with the seizure in the horsecar, and carried unconscious 
to the sidewalk. The opisthotonic position in her case is 
most marked. Creeping sensations precede the attacks, 
and there is always occipital headache. There is also ex- 
treme constipation, sometimes lasting a week. She has 
had these 'attacks now for several months. The first was 
caused by the fright of being chased at night by a man. 
Menses are scanty, with terrible dysmenorrhceal pains, 
and last only a day and a half. 

Case X. — Hystero-Epilepsy ; Left Ovarian Hyper- 
esthesia, Much Delirium, Dysmenorrhoea, Slight Flow, 
Endometritis, Constant Leucorrhoza. — Mrs. S., age 27, 
has been married five years; she is strongly built. She has 
had attacks of hystero-epilepsy for the past seven years, 
coming on at first from a fright. The first sensation is 
that of trembling. Her hands become cold and there is 
dizziness or faintness, followed by unconsciousness, until 
the period of contortions, when consciousness returns. Dur- 
ing the attack she assumes the opisthotonic position, and 
froths at the mouth, the froth being frequently tinged with 
blood. She believes the severe abdominal pain to be the 
cause of the attack, although it may be brought on by other 
things. She is excessively nervous and depressed after it. 
Headaches are usually in the vertex, but are sometimes 
occipital; she is always nauseated upon rising and after 
eating; she has a voracious appetite; she is always con- 
stipated. There is pain in the left ovarian region. A 
cold drink always gives severe cutting pains in the hypo- 
gastrium. Menstruation lasts from one day and a half to 
two days, and pain comes on about a day later. She has 
much anxiety on account of a worthless husband. 

Examination: At the internal so, on passage of the 
sound, there is great sensitiveness. She has constant 
leucorrhcea. Since treatment directed to the uterus and 
ovaries, the attacks are much less frequent and less severe. 

Finally, after a short time the headaches left, her menses 



HYSTERO- EPILEPSY. 219 

became normal, pain ceased, and she was apparently en- 
tirely cured. 

Criminal abortion, with its resulting local disease and 
its injurious effect upon the mind, is a common factor in 
the causation of these cases. As a class, hystero-epileptics 
are inferior and unintelligent, and full of humbug, pre- 
tense, and vanity. They are, as a rule, weak-minded 
creatures. 

Case XI.—Hystero-Epilepsy; Ovarian Hyperesthe- 
sia, Trance or Epileptoid State, Hysterical Trismus, 
Amblyopia an Ophthalmic Hystero- Neurosis, Dysmen- 
orrhea, Endometritis, Perimetritis, Two Criminal 
Abortions. — Mrs. L., age 32, has been married ten years, 
and has one child. She has had two criminal abortions at six 
weeks. When a girl, she had attacks which, from descrip- 
tion, were probably hystero-epileptic, and had dysmenor- 
rhcea until she became pregnant. She has had two hys- 
tero-epileptic attacks during the past year. She also has 
nervous spells, when she grows cold, and there is a roaring 
and throbbing in the head and a blurring of the vision. 
It is not a fainting condition. She thinks that she has 
warded off some of these nervous spells by her will power. 
Occasionally in the afternoon, while taking a light sleep 
on the bed or sofa, this state comes od. She remains 
conscious, but cannot stir hand or foot; her extremities 
feel as cold as ice. During this state she is "frightened 
and prays for God's help to move." She has a sensation 
of shaking or quivering through every part of the body. 
She dreams a great deal at night. A short time ago she 
consulted me for hysterical trismus; it passed away and 
"went to the stomach," as she expressed it, when I was 
called and had to give her a hypodermic injection to re- 
lieve the pain. She has had hysterical lockjaw twice be- 
fore, and her doctor said "it was the wisdom tooth, that 
didn't have room to come through." She has chronic 
endometritis and perimetritis. 



220 FUNCTIONAL NERVOUS DISORDERS. 

It will be of interest to contrast the following case with 
the foregoing, as the two conditions are sometimes con- 
sidered to be the same. The hysteric element is here 
entirely wanting. 

Case XII. — Haut Mai ; Menses Habitually Delayed, 
Amblyopia, No Hysterical Symptoms, Has an Ovarian 
Aura. — Mrs. C, age 22, was married at nineteen, and 
has one child. She first menstruated at fifteen, and the 
period usually occurs every five or six weeks. The first 
attack occurred a year after marriage, and it came on, as 
have her succeeding attacks, when she was expecting her 
menses. At the time for regular menstruation, there 
comes a sensation of weight in the hypogastrium, and 
while waiting for the flow, which is always scanty, to 
appear, the blood seems to rush to her head upon the 
slightest exertion, with a feeling as if her head would 
burst. The eyes are affected with a blurring of vision, 
and most of the pain is frontal. During the attack she 
grows pale, there is strabismus, and the muscles of the 
face are contracted. In the last attack several teeth were 
broken. Her last menstruation was delayed twenty days. 
She has no hysterical symptoms whatever. As soon as 
the menstrual flow appears she feels all right. 

Case XIII. — Convulsions with Dysmenorrhea, Nei- 
ther Hysteric nor Epileptic. — Miss B. S., age 37, for 
fourteen years had little trouble at the menstrual period ; 
menses first appeared at 18, and then stopped for a year. 
She thinks the flow was never regular; it was always 
slight in amount, lasting from one to two days. When 23 
years old, while lifting a heavy tub, she " felt something 
break inside," and has been ill ever since. She has pains 
of a very severe cutting nature in the left ovarian region, 
very severe congestive and neuralgic occipito-basal and 
frontal headaches, with much swelling of the face and 
neck. These come on as menstruation stops, rarely before 
it appears, and are preceded by severe shakings or convul- 
sions. She does not feel cold, neither is there any fever. 



HYSTERO-EPILEPSY. 221 

Slight pressure over the left ovarian region gives a little 
relief, but severe pressure causes great pain and increases 
the convulsive trembling. There is no loss of conscious- 
ness, and there are no hysterical manifestations. She has 
lately developed an asthmatic neurosis. When the attack 
skips one menstrual period, it comes with redoubled force 
the next time. Local treatment with boro-gylceride tam- 
pons and hot-water irrigation always improves her con- 
dition. Bromide of potassium and morphine injections 
help the headaches. She has a tender and inflamed uterus. 



Catalepsy, Trance, Lethargy, Somnambulism, Cata- 
leptoicl State. — Trance, lethargy, somnambulism, and 
hystero-catalepsy are probably only modifications of the 
same state; lethargy and trance are often complicated 
with cataleptic phenomena, and the cataleptoid state can 
easily be impressed on either. Somnambulism often ap- 
pears in the great hysterical attack as one of its promi- 
nent features. Catalepsy in these cases is sometimes 
limited to the upper extremities, and to impress a catalep- 
toid state on the subject of trance or lethargy the member 
should be held for a few seconds, when it usually becomes 
rigid, and then again by friction the catalepsy may be 
made to disappear. In all these conditions there is fre- 
quently great mental activity. 

Richer divides lethargy into the following varieties : 

1. Attacks of simple lethargy. 

2. Attacks of lethargy with apparent death. 

3. Attacks of complicated lethargy. 

(a) By contractions, partial or general. 

(b) By cataleptoid state. 

Attacks of trance or lethargy with apparent death have 
been recorded by reputable writers, and there is but little 
doubt that some persons in this state have been buried 



222 



FUNCTIONAL NERVOUS DISORDERS. 



alive. Catalepsy or trance may be defined as a state in 
which general motion and sensation are suspended, but 
some one or more of the special senses remain active. In 
this state there is probably local or general modification of 
the cerebral circulation. 

The following contrast is made by Richer : 



Catalepsy. 

The cataleptic state is general, 
affecting equally all the volun- 
tary muscles. 

The cataleptic state is de- 
veloped instantly ; the member 
keeps the position as soon as 
communicated. 

Suppleness and lightness of 
the members. 

No rigidity of the members. 

The cataleptic state is in no 
nanner influenced by superficial 
cutaneous excitations. 

The cataleptic state is primi- 
tive. 



Cataleptoid State of Somnam- 
bulism. 

The cataleptoid state is partial. 

The cataleptoid state comes 
gradually after superficial cutane- 
ous excitation (passes, currents 
of air, blowing, etc.). 

The members are always in a 
state of rigidity, of which the 
degree varies from waxen flexi- 
bility up to contracture. 

The cataleptoid state ceases in 
the same manner in which it 
has been provoked, that is to say, 
after superficial cutaneous exci- 
tations. 

The cataleptoid state is sec- 



ondary. 

Catalepsy is not properly speaking a disease per se, but 
is merely one of the train of manifestations of affections 
of the nervous system. It is a far more common condition 
in weak and hysterical women than is generally supposed. 
There is, as a rule, no danger connected with it. Attacks 
vary in duration from a few minutes to many days. It is 
a. disorder in which there is loss of consciousness, sensation, 
and voluntary motion, attended with a remarkable rigidity 
of the body. In some cases there is a deprivation of mus- 
cular power with perfect consciousness existing, while in 
other cases the condition is similar to that of deep sleep, 
from which the individual awakens without the slightest 
recollection of anything that has occurred. In the severe 



HYSTERO-EPILEPSY. 



223 




224 FUNCTIONAL NERVOUS DISORDERS. 

cases there may be a complete suspension of consciousness 
and volition, but in the more common type, which occurs, 
with considerable frequency, volition is usually sup- 
pressed, while consciousness remains unimpaired. Severe- 
and prolonged attacks of this disease, lasting for many 
days, are uncommon. There are states allied to catalepsy 
in which sensation only is abolished, the power of motion 
remaining perfect. Catalepsy has been frequently mis- 
taken for death itself; as a rule, the breathing is light and 
almost imperceptible, although in some cases which I have> 
seen it was of a stertorous character. The skin is of a. 
pale and death-like hue; the pulse is usually feeble and 
frequently accelerated. 

This condition is not very rare when disease of the brain 
is present, and it often coexists with insanity. It is cer- 
tainly a curious and interesting affection, and, being of a 
rather marvellous type, is a subject of great interest to 
non-medical readers. 

The daily newspapers frequently publish cases of cata- 
lepsy or trance; the result of reading the articles is to 
excite a dread of being buried alive, and is thus the cause 
of considerable mental suffering among weak-minded peo- 
ple. As undoubted cases of this horrible occurrence are 
upon record, it is essential that the condition should re- 
ceive from the physician the study and investigation 
which it deserves. 

The following case of trance was described to me by a 
patient, an exceedingly intelligent woman and a close 
observer, who was an eye-witness of the occurrence. 

Case I. — Mrs. K. L. is 48 years old, and extremely ner- 
vous; she has had one child. Her husband, a sea captain, 
causes her a great deal of worry on account of his vicious 
behavior. Her affection for him is very great, but he does 



HYSTERO-EPILEPSY. ■ 225 

not return it. She is tall and rather emaciated, has dark 
hair and gray eyes, and a sallow complexion. For the past 
five years, she has been having so-called "fainting-fits." 
These come on suddenly, and she usually comes out of 
them in from half an hour to an hour. On one occasion, 
exhausted from the exertion of ironing a dress for her 
daughter of 12 years, she fell into one of these fits, and 
remained without motion from 7 p.m. until 10 p.m. the 
next night — near twenty-seven hours. She was cold and 
seemed to be perfectly lifeless. Those in attendance ap- 
plied a hand mirror to her mouth to see if there was any 
respiration to deposit moisture upon it, but there seemed 
to be none. After this incomplete test the neighbors pro- 
nounced her dead and proceeded to make her shroud. 
Dr. John Osborne was called, and said that she was liv- 
ing. He requested to be called again if there were any 
change in her condition. During these twenty-seven 
hours, Mrs. L. says that she was conscious of every word 
that was spoken, and of course heard the remarks about 
her supposed death. She said her only hope was that 
when her child returned from the entertainment to which 
she had gone, she would in her fright throw herself upon 
her neck and awaken her. She was unable to see, but 
hearing was normal. Attempts were made to administer 
food, but she could not swallow. She claims to have been 
entirely conscious the whole time, and must have endured 
agonies of mental torture. A pricking sensation in the 
lower limbs ushered in a gradual return to a waking state. 
The attack was followed by shivering. She said that she 
was quite convinced that they would bury her alive. She 
thought that the attack had some connection with the 
menopause. She lived for fifteen years after this incident. 

In cases of apparent death in the state of catalepsy, 

every effort should be made to resuscitate the patient by 

means of galvanism, transfusion, etc. ; and in many cases 

where death seems to have occurred beyond a doubt our 

efforts will be crowned with success. Decomposition is 
15 



226 FUNCTIONAL NERVOUS DISORDERS. 

the only positive, irrefutable evidence of death. The vital 

spark may be latent, only needing the application of fara- 

dism or galvanism, or both, to fan it again into activity. 

There is no doubt whatever that many persons have been 

buried alive in a state of catalepsy who might have been 

'i 

restored to life, had the proper means been taken for their 
reanimation. 

In my opinion, the efforts to resuscitate the apparently 
dead in this condition should end only with the appear- 
ance of evidences of commencing decomposition. 

Attacks of trance frequently alternate with attacks of 
hystero-epilepsy. They are undoubtedly dependent upon 
some form of vasomotor disturbance in the cerebral circu- 
lation. In these cases, the pulse in the beginning of the 
attack is extremely rapid and irregular; afterward it 
becomes less frequent and more feeble, dropping down to 
40, and finally being quite imperceptible at the wrist. 
In some cases even the heart cannot be heard to beat with- 
out careful auscultation with the stethoscope. Under such 
conditions a person might easily be buried alive. In the 
cases under discussion, neither respiration nor circulation 
is perceptible, the patient frequently lying in this con- 
dition for hours or even days. 

The onset of catalepsy is very rarely sudden ; there are 
usually some premonitory symptoms, e.g., headache, in- 
somnia, nervous irritability or excitement, illusions, and 
sometimes convulsions of a mild character. At the time 
of the seizure the entire muscular s} T stem is affected with 
a sudden rigidity. Cases are rare in which only certain 
limbs are affected. The muscles for a time are fixed, and 
the limbs can be neither flexed nor extended, the patient 
remaining in the exact position she was in at the time of 
the attack. The eyes are often directed upward, having 



HYSTERO-EPILEPSY. 22? 

a wild, staring expression. Sometimes the lids are closed, 
but usually they remain open. After a period of fixed 
rigidity, the muscles assume the condition known as 
" waxen flexibility" ; the limbs or fingers can be placed in 
any, even the most abnormal, position, and will remain as 
placed for a considerable length of time. A patient can 
even be stood upright on his feet, and with the very slight- 
est support will retain that position. 

The patient upon recovery has no recollection of what 
has occurred during the attack, and in some severe cases 
anaesthesia and analgesia are present ; in others, however, 
the patient retains sensibility to a certain extent, but reflex 
movement is absent; the nostrils or the soles of the feet 
may be tickled without eliciting any manifestations of 
sensation. In some cases the conjunctiva may retain its 
sensibility. The functions of the bladder and bowels are 
performed slowly; a piece of food introduced into the 
pharynx is usually swallowed without difficulty. In some 
cases, after the power of voluntary motion has been recov- 
ered, the " waxen flexibility" of the limbs may still persist. 

Some patients while in the cataleptic state have a per- 
fect consciousness of everything that is transpiring around 
them; others have a partial and indistinct idea of what is 
happening; while others again are totally oblivious to 
their surroundings and their loss of consciousness is com- 
plete. The recovery from one of these attacks is always 
sudden ; the patient starts up with a yawn or a sigh, as if 
from a deep sleep. 

The paroxysms, as a rule, at first occur without any 
regularity. After the initial attacks the patients are usu- 
ally in good health, but after the occurrence of many and 
severe seizures they suffer for some time from hysterical 
symptoms, headache, vertigo, and general prostration. 



228 



FUNCTIONAL NERVOUS DISORDERS. 



The causes of catalepsy are very seldom local, but affect 
the entire system. Nervous, hysterical women are the 
most common subjects. Violent emotions, mental excite- 
ment, impaired diges- 
tion, disordered menstru- 
ation, nervous exhaus- 
tion, and similar causes 
are the exciting factors 
of this condition. The 
seizures are most common 
in young adults, about the 
beginning of the period 
of active uterine life, or 
in those more advanced 
in life who have uterine 
disease. 

Dr. Gooch relates the 
following case, which is 
a good example of the 
disorder : 



The patient was a 
woman, the victim of 
melancholi a. Shortly 
after parturition she was 
seized with the cataleptic 
attack, and presented 
the following appearan- 
ces: 

She was lying in bed 
motionless and apparent- 
ly senseless. It was 




Fig. 26.— Catalepsy in Melancholia. Patient 
keeps this position for half an hour with- 
out moving. 



thought the pupils of her eyes were dilated, and some 
apprehensions were entertained of effusion on the brain j 
but on examining them closely it was found they read- 



HYSTERO-EPILEPST. 229 

ily contracted when the light fell upon them. Her 
eyes were open, but there was no rising of the chest, 
no movement of the nostril, no appearance of respiration. 
The only signs of life were warmth and a pulse which was 
120, and weak. Her fseces and urine had been voided in 
bed. In attempting to rouse her from this senseless state 
the trunk of the body was lifted up and placed so far back 
as to form an obtuse angle with the lower extremities, and 
in this posture, with nothing to support her, she continued 
sitting for many minutes. One arm was now raised, and 
then the other, and in the posture they were placed they 
remained. It was a curious sight to see her sitting up 
staring lifelessly, her arms outstretched, yet without any 
visible signs of animation. She was very thin and pallid, 
and looked like a corpse that had been propped up and 
stiffened in that attitude. She was now taken out of bed 
and placed upright, and attempts were made to rouse her 
by calling loudly in her ears, but in vain ; she stood up, 
indeed, but as inanimate as a statue. The slightest push 
put her off her balance, and she made no exertion to regain 
it, and would have fallen had she not been caught. She 
went into this state three times ; the first lasted fourteen 
hours, the second twelve hours, and the third nine hours, 
with waking intervals of three days after the first fit, and 
of one day after the second; after this time the disease 
assumed the ordinary form of melancholia. 

The case of M. C, which follows, shows the effect of 
malarial fever, together with exhausting uterine disease, 
in the production of the lethargic or trance state. Exces- 
sive leucorrhoea in frail, delicate women is not only pro- 
ductive of profound nervous disturbances and physical 
exhaustion, but, in a great number of young women, is 
the principal causative factor in the production of phthisis. 
The leucorrhoea in these cases is usually secondary to the 
maldigestion, although sometimes it precedes it. The 
case especially shows the well-known value of Fowler's 



230 FUNCTIONAL NERVOUS DISORDERS. 

solution as a tonic in these conditions of exhaustion of the 
nervous system. 

Case II.— Lethargy, Trance, Recurrent Orgasm De- 
pendent upon Oophoritis, Endocervicitis, and Leucor- 
rhcea. — Miss M. C, teacher, age about 26, is frail and very 
delicate. A few months previous to her first menses, 
which commenced at 14, this patient had her first attack, 
during which she could neither speak nor move, but was 
perfectly conscious. In 1873, she had a severe attack of 
chills and fever and has since suffered more or less from 
malaria. She has always been a heavy sleeper, and al- 
though she has done all she could to combat her drowsi- 
ness, it would overcome her, no matter what position she 
would take. She has slept standing, sitting, and kneeling ; 
her head during this time would seem of a ton weight. 
In 1879 she became very nervous, and for two or three 
months she slept from twelve to fourteen hours each day, 
and even then she still felt drowsy, but her head was much 
relieved. Part of the time she had a feeling as if an iron 
band were tightly pressing the crown of the head. Leu- 
corrhcea then commenced, and has continued more or less 
ever since. In the summer of 1886 she was very weak, 
and afternoons while resting, and oftentimes before going 
to sleep at night, she would have the following sensations: 
At first she would lose all power of feeling in the hands 
and feet, until gradually the whole body became numb; at 
the same time she had the hallucination that she was as- 
suming immense proportions, each tooth seeming to ex- 
pand, and she could feel the nerve of each separate one 
throbbing. Very often at this stage she would jump up in 
great fright, her heart beating violently and the whole 
body trembling; at others, after a while she would fall 
into a heavy sleep. At other times on awakening she was 
conscious of all that happened around her, but was utterly 
unable to move or speak. She has recognized persons 
entering the room, heard what they said, and has done her 
utmost to let them know she was awake, but could not 



HYSTERO-EPILEPSY. 231 

move a voluntary muscle of her body. She has, at such 
times, tried to move a finger or a toe or an eyelid, but could 
not succeed. She has sometimes been an hour trying to 
rouse herself out of this state, and when at last she suc- 
ceeded, the efforts made would leave her very much ex- 
hausted and bring on a severe palpitation of the heart. 
She had these attacks very often during the summer and 
autumn of 1886, but was not seriously ill until December, 
when I first saw her. She was then very feeble, but under 
treatment improved greatly. In April, 1887, she began 
to have recurrent orgasms, which occurred regularly ten 
days after menstruation, continuing daily for a week. 
These lasted until July, and caused a return of the cata- 
leptoid state. On examination, the uterus was found ten- 
der and eroded, with tenderness and enlargement of both 
ovaries. She was given phosphorus pills, Fowler's solu- 
tion in large doses, and fly blisters were applied over the 
ovarian region. Electricity (faradic current) increased 
the number of orgasms. Fowler's solution produced great 
improvement, and she now enjoys good health. 

Case III. — Trance or Cataleptoid State; Ovarian 
Hypercesthesia, Cervix Eroded, Dysmenorrhcea, Leu- 
corrhcea. — Miss A. B., age 23, has severe headaches 
which come on before the menses ; very severe pain in the 
left ovarian region comes on with the menstral flow. She 
has leucorrhcea, and on examination the pelvic peritoneal 
plane is found to be very sensitive ; the cervix is eroded. 
She is at times very hysterical. She has had an attack 
of severe pain in the epigastrium during which she w r as 
cataleptoid; this persisted for a considerable time. Under 
treatment by curative exercise, hydrotherapy, and massage 
she made a good recovery. 

Excessive fright is a common cause of severe functional 
nervous disease, as is also a lack of judicious restraint 
upon the emotions. Jealousy, as in the following case, is 



232 FUNCTIONAL NERVOUS DISORDERS. 

a common cause of hysterical manifestations in those who 
are the victims of defective hygiene. 

Case IV. — Hystero- Catalepsy ; Trance, Ovarian 
Hypercesthesia, Menorrhagia. — Miss L. L., age 18. 
Her father is dead, her mother a drunkard and quarrel- 
some. January 10th, 1888. Her first attack was six 
months ago from a fright, some one having placed a 
" stuffed man" in her bed. This attack lasted three hours 
and was followed by slighter attacks. A month ago she 
had another severe attack, has been very nervous, and is 
jealous of her lover. She has had a severe cold. At 2 
P.M. to-day, she went off into a "sort of faint"; there 
were no twitchings nor convulsions. When I saw her, 
her pupils were contracted to pinhead size. She has 
general cutaneous anaesthesia, responding but slightly to 
severe tests. Pulse is jerky and irregular, limbs in a 
cataleptoid state, skin cold, and she looks like death. 
January 11th, her condition was unchanged. Suddenly 
she gives a jerk, throws both arms backward and extends 
them, and goes into an ecstatic condition. During the 
attack she has very marked internal strabismus and is 
cataleptoid. Later I learned that the bowels have been 
constipated for five days, and that she has pain in the 
back of the head and precordial region. She has had 
dysmenorrhcea ever since the function of menstruation 
was established. During the last month she has men- 
struated twice and very profusely. There is ovarian 
hyperesthesia. 

Mistakes in diagnosis are of course frequent, but the 
error made in the following case should serve to put us all 
upon our guard against classifying simple functional reflex 
disorders as cases of profound local disease. The case also 
shows what has been noted in other instances, that not 
only a condition of anaemia but one of supposed cerebral 
hyperemia may precede the cataleptoid state. A sensa- 



HYSTERO-EPILEPST. 233 

tion as of hammering at the vertex, joined to excessive 
redness of the face, has been noted in many patients suffer- 
ing from various functional nervous disorders. 

Case V. — Trance of Cataleptoid State j Spinal Irri- 
tation, Globus Hystericus, Endometritis, Leucorrhcea, 
Retroflexion, Menstruation Never Regular. — Miss M. 
KT., single, age 26, menstruated first at 20; at 17 she had a 
discharge of thick, yellowish leucorrhoea, which continued 
a year and six months; she was kept in bed thirteen 
months by a physician (for supposed suppurating spinal 
disease discharging by the vagina). The spine is tender 
from the middle dorsal region to the coccyx, this tender- 
ness having been very marked at the time when the physi- 
cian ordered her to keep to her bed. At the time when 
the menses were appearing, she had an attack of vicarious 
hemorrhage from the stomach. Menstruation is never 
regular. She has pain in the temples and neuralgic head- 
ache; the skin is sensitive. There is a bright flush on 
both malar bones, and the least excitement gives her a 
momentary but intense blush. The tongue is coated 
white; pulse 100, strong and full; stomach swollen. She 
has pain in the left ovarian region, extending to the back. 
Since the age of 18 she has had attacks in which she was 
sleepless and frightened at night. The attacks came, both 
when asleep and awake, with a sensation of compression 
in the brain, the face being at this time very red, and 
were followed by a creeping sensation beginning at the 
toes and fingers and going to the head ; then ensued a cata- 
leptoid state. She could moan but could do nothing else — 
could stir neither hands nor feet. To-day, May 20th, 1889, 
the globus hystericus " is one minute in the throat, and the 
next back again to the left ovarian region." She has cold 
and clammy feet and hands. Appetite is poor, and she 
is easily nauseated. On examination I find endometritis 
and retroflexion. 

Agonizing and unbearable pain, not only in the ovarian 
but in the epigastric region, is a very common, if not the 



:; : i . N JTIOXAL 8TERV0US sob 

most frequent, exciting cause ;: both hystero- epilepsy and 
[ : the catalej toid state. 

Case VI. — Tn / Cataleptoid State; Ovarian 

srcesthes \ . . :. Palpitations, LaceraU 
n\i\ Granulations. — Mrs. L. is a widow, age 30, Her 

attack .: hystero-eataleptoid state comes on from agoniz- 
ing pain in the ovarian region before menstruation : she is 
constantly nauseated, and is very nervous. The a: 
lasts but a tew minutes: she rinds it impossible to move 
or speak, "is oold as ice," and sweats profusely. It is 
sometimes followed by extreme prostration. She has mi- 
graine. Examination reveals laceration of the cervix on 
the left side, with granulations. 

Case VII. — Airs. K.j 33 years of age. is a nullipara, al- 
though married for a number of years. December 10th, 
IS! C she complained of feeling very badly: her head was 
sore from neuralgia, she had no appetite, her stomach was 
distended, and her tongue was heavily coated. I 
just succeeded in relieving her of a tapeworm in the fol- 
lowing manner: I prescribed a mixture containing . 
hm of kretol to four ounces of water, of which she 
took a dessertspoonful every two hours. This was fol- 
lowed by a large dose of castor oil. and within an hour the 
worm was brought away complete. Before this she had 
been suffering much with " bloating" of the belly and 
s in the legs, and had had grinding of the teeth at 
night. 

The excessive evacuations produced by the castor oil 
made her feel very weak, and while sleeping the trance or 
cataleptoid state came on. She heard the letter carrier 
: ing the door bell, but could not get up to answer it. She 
knew where she was and tried very hard to move, but 
found it impossible. There was " no dream about it" : it 
- simply that she was powerless to move. When she 
finally came out of this state, her feet "felt as heavy as 
lead." and she could not be induced to lie down again for 
tear of a return of the attack. 



HYSTERO-EPILEPSY. 235 

In her case, the condition of the digestive organs and 
the anaemia present, together with the excessive drain 
upon her system from the energetic action of the oil, were 
sufficient to induce this cataleptoid attack. 

The following case illustrates a mild form of trance or 
the cataleptoid state, or an allied condition. 

Case VIII. — Mary G., 27 years of age. The disease 
began with great mental worry. She is now extremely 
nervous. She has had three attacks in which her legs 
" gave way" ; she becomes suddenly weak and numb all 
over the body. These attacks do not last very long ; they 
are not the same as attacks of syncope, but consist of a 
sudden numbness or powerlessness. At the present mo- 
ment, although her appetite is fair and her color good, her 
feet and hands are numb, and she frequently experiences 
creeping sensations in the extremities. The attacks come 
on with a severe nervous chill, and are followed by hys- 
terical trembling. 

Under dietetic and medical treatment she recovered. 

The following case of cataleptoid state illustrates the 
intimate connection between the digestive and nervous 
systems, and the dependence of nervous manifestations 
upon malassimilation, these conditions resulting from 
overwork and bad food. 

Case IX. — Agnes G., an anaemic young girl, suffers 
severely with frontal headaches, which come on three 
days before menstruation. The face during this time feels 
cold, and there is a sensation of coldness on the vertex as 
if it had been " wet with cold water:" 

I frequently find that the headaches of anaemia are also 
present immediately before menstruation. In this case 
there were also severe cramps of anaemic dysmenorrhcea 
coming on immediately after the appearance of the flow. 
The pain is most severe in the left ovarian region and in 



236 FUNCTIONAL NERVOUS DISORDERS. 

the back ; her feet " are never warm." On vaginal exami- 
nation I find considerable leucorrhcea present, and the 
peritoneal plane is considerably inflamed and quite sensi- 
tive. She consults me principally for severe attacks of 
gastric pain, during which she completely loses control of 
herself, and can neither speak nor move. This state lasts 
for the space of twenty minutes or more. After a time 
she gradually recovers both motion and sensation. Her 
digestion is markedly embarrassed, as the result of over- 
work and a bad selection of food. She takes strong tea 
in large amounts. 

Ecstasy. 

Ecstasy is a state of the system in which the mind is 
apparently absorbed by some dominant idea, the patients 
being at the time totally insensible to their surroundings. 
The condition is somewhat similar to that of catalepsy, and 
is by many authors considered to be identical with trance, 
of which it is probably a form. It is frequently present 
after a hystero-epileptic attack. The visual hallucina- 
tions which often occur are the most remarkable features 
of this condition. The mind is active and the visions are 
remembered after the attacks are over. In cataleps}^, 
however, there is usually total oblivion during the attack. 
At this time the pulse remains normal. Attacks are often 
epidemic during periods of religious excitement, when 
they usually take the simpler forms of the maladj\, They 
are quite common at negro revivals and among the primi- 
tive Methodists. The "convulsionnaires" were a set of 
religious ecstatics existing before the French revolution. 
The Dervishes in Egypt, and the Jumpers of eastern 
Maine and New York, are also specimens of this class of 
religious contortionists, who suffer from a mild form of 
mania. The disease is communicable by imitation, espe- 



HYSTERO-EPILEPSY. 237 

cially among the ignorant. "Mocking is catching," not 
only among children but among adults, and especially is 
this so when the disease is epidemic and its manifestations 
assume the more noisy and ridiculous forms. This was 
seen in the spasmodic epidemics of the Middle Ages. The 
dancing-mania lasted for a period of one hundred and fifty 
years in Germany. Many of these ecstatic cranks pretend 
to find in the Bible examples to justify their capers. 

Among the exciting causes of ecstasy, emotional dis- 
turbances, especially of a perverted religious character, 
are the most prominent. 

Severe and prompt measures should be used to suppress 
these epidemics. At one time, in the Infirmary for Chil- 
dren and Young Girls, I had an epidemic of chorea in 
which about a dozen children were affected. Isolation, 
with but little other treatment except Fowler's solu- 
tion, was sufficient to cause its almost immediate disap- 
pearance. 

Somnambulism. 

Somnambulism is frequently present in cases of hystero- 
epilepsy as a part of the attack, following the more pro- 
found disturbances. It seems to be a very mild form of 
delirium or cerebral irritation. The mildest type consists 
simply of talking during sleep, but in the more severe 
forms the patient leaves the bed and walks about, and if 
the cerebral excitement be still more marked he even goes 
into the street and walks long distances. It is quite com- 
mon in nervous and excitable children who are fed freely 
upon indigestible food. Adults who are subject to it are 
usually such as are suffering from profound mental anx- 
iety, or who are engaged in exhausting mental occupation. 

Upon awaking in the morning there may sometimes be 



238 FUNCTIONAL NERVOUS DISORDERS. 

a faint recollection of what has occurred, as the disease is 
really only a very pronounced form of dreaming of which 
movement forms a part. A good description of a typical 
case is given by Shakespeare in his portrayal of Lady 
Macbeth. 

In the treatment special attention should be given to 
diet and the condition of the digestive organs. The men- 
tal state previous to retiring should be calm. Precautions 
should be taken to have the windows of the somnambu- 
list's room so fixed that he cannot walk or fall out of them, 
as many have received serious harm in this manner. 

Cerebral excitement resulting from excess of the emo- 
tions, or from intellectual exertion, are causative factors 
in this disease, and should be avoided. Overloading and 
embarrassing the digestive organs with an excess of greasy 
and improperly prepared food tends to disturbance of the 
cerebral circulation by causing hyperemia, with somnam- 
bulism as a result. In some young patients somnambu- 
lism tends to become a habit. It is well to sleep with the 
head well raised. Only light meals of easily digested food 
should be taken several hours before retiring, and fully an 
hour before a glass of hot water should be drunk to re- 
move gastro-intestinal irritations and act as a sedative to 
the digestive tract. When the hot water is taken immedi- 
ately before retiring it acts as a stimulant to the circula- 
tion and induces cerebral hypersemia. There are some 
patients who require a little food, such as a cracker or a 
piece of toast and a small glass of milk very shortly be- 
fore retiring, and who cannot sleep without it. When 
such patients are subject to somnambulism, the greatest 
care should be exercised that only the smallest amount of 
food is taken, as indigestion predisposes to cerebral con- 
gestion, which is already present in these cases. 



HYSTERO-EPILEPSY. 239 

One method of arresting the attack of somnambulism is 
to place a slab of marble, a piece of sheet-iron, zinc, oil- 
cloth, or any such cold body beside the bed, in such a 
position that the sleepwalker must first step upon it. As 
a rule, he will go no further ; the cold thrill sent through 
him will partially awaken him, and he will return to bed. 

Insomnia. 

Cerebral hyperemia is the most common factor in the 
production of wakefulness. An excited or active state of 
the brain, with an increased amount of blood in its tissues, 
are the conditions usually present. The removal of the 
irritation and hyperemia is therefore essential before sleep 
can be procured. After great mental strain or great phys- 
ical effort, insomnia usually follows, due probably in these 
cases to hyperaemia of the brain as a result of weakened 
heart action. Where there is an exhaustion of the vaso- 
motor nerves, there is a deficient tone in the cerebral ves- 
sels, and a passive hyperaemia results. 

Cerebral anaemia is, as a rule, present when the patient 
is drowsy, although in diseased states wakefulness may 
be produced by it. Insomnia should in many cases be 
looked upon as a neurosis dependent upon disease of the 
liver and other organs. Patients suffering from severe 
malarial fever seldom sleep well, and in these cases the 
h} T pnotic action of quinine is marked, in addition to its 
other valuable properties. In conditions of exhausted 
nerve force with insomnia, the stimulation arising from 
a full meal often causes the patient to become drowsy and 
sink into a sound sleep. The irritation of an empty stom- 
ach and the consequent cerebral hyperaemia cause much 
wakefulness. It is a custom with many persons to take a 



240 FUNCTIONAL NERVOUS DISORDERS. 

sandwich and a glass of light beer before retiring, and in 
fact anything which stimulates the solar plexus of the 
sympathetic in these cases has a soporific action. I do 
not, however, consider this to be a good practice, as 
digestion is always markedly slower and more feeble dur- 
ing sleep. The drinking of coffee and tea, even in mode- 
ration, will sometimes, especially in those unaccustomed 
to their use, prevent sleep. Wines, especially those diffi- 
cult of digestion, when taken in moderate amount, may 
produce wakefulness, but copious libations would probably 
produce the opposite effect. Monotonous sounds or the 
reading of uninteresting books have a soporific influence, 
as has the counting of numbers in a chanting manner. 
The monk's prescription of " telling the beads" is a good 
method of inducing sleep, or one may gaze fixedly at some 
object upon the ceiling. Winking for the space of one or 
two minutes has been recommended among a variety of 
other measures. Opium in moderate doses is a useful 
drug, but it should be carefully handled for fear of caus- 
ing the opium habit. It should not be given by hypoder- 
mic injection except for the relief of very acute pain. 
Hyoscyamus, the bromides, belladonna, and in some cases 
cannabis indica, and alcoholic beverages are useful. 

Chorea. 

Chorea Minor. — Chorea, or the disease commonly 
known as St. Vitus' dance, is a functional nervous affec- 
tion which usually occurs in childhood, is quite often 
met with in young women, and is found sometimes dur- 
ing pregnancy. Rarely also it may manifest itself at 
the menopause. From the period of the second dentition 
until about the age of nine years, both sexes seem to be 



HYSTEKO-EPILEPST. 241 

'equally liable, but after that age, according to Sir Thomas 
Watson, females are more prone to the disease than males, 
in the proportion of about five to two. 

This disorder is characterized by defects of voluntary 
co-ordination, by clonic spasmodic movements of the vol- 
untary muscles, and by a certain degree of weakness, more 
or less appoaching to paralysis, in the affected parts. The 
movements usually subside during sleep. They are some- 
times unilateral, the left being the side most frequently 
affected. This variety is called hemichorea. The pa- 
tients are usually anaemic, the mind is weakened, and 
there is much irritability of temper. Anaesthesia is some- 
times present. As the disease is a neurosis, there are no 
characteristic anatomical changes to be found in fatal 
cases. Its causation depends upon anaemia, the result of 
defective diet and hygiene. The exciting cause may be a 
fright, or any violent disturbance of the emotions. It is 
in children often associated with rheumatism. 

Many remedies have been employed for the relief of this 
condition. I have had the best success with Fowler's solu- 
tion in large doses. In an epidemic of this disorder which 
occurred at the Infirmary for Children and Young Girls, 
every case recovered under its administration combined 
with isolation to obviate the mental contagion. It is 
lauded by many as a specific for the disease. Strychnine, 
iron, and opium have also been used with much benefit, as 
have also the oxide of zinc, valerian, camphor, and asa- 
fcetida. Chloroform and ether given internally are said 
by some to be of advantage on account of their antispas- 
modic action. I have had no experience with them. 
Careful alimentation is of the greatest importance. 

Dr. Hermann Nebel, in his classic monograph, "The 

Mechanical Treatment of Chorea, A Historico-Critical 
16 



242 FUNCTIONAL NERVOUS DISORDERS. 

Study," translated by Dr. L. Wischnewetzky, has com-* 
pletely covered the subject and given the best means of 
treatment for this affection. 

Chorea Major. — The term chorea has been made to 
include almost all forms of involuntary movements in 
which distinct spasm or a pronounced tremor does not 
exist — salaam convulsions, moving the head back and 
forth in a half -rotary manner, bowing, bobbing, and oscil- 
lating movements. In its severe type it is a very grave 
disorder and most distressing to witness, the patient cease- 
lessly tossing herself in all directions and being kept in 
bed only by means of straps. Headache, delirium, and 
even coma are often present. The digestive organs are 
always more or less involved, as indicated by anorexia, 
gastralgia, or vomiting. 

Chorea major has often assumed an epidemic character. 
In 1418 an epidemic broke out in Strasburg which took 
the form of uncontrollable dancing, leaping, and scream- 
ing. Sometimes the epidemics are of a decidedly hyster- 
ical type, characterized by fits of laughter, dancing, crying, 
screaming and howling, associated with mental delusions, 
and with eructations. The disease has been common in 
France, Germany, and Italy. In England and America 
we have the Jumpers and Shakers, victims of religious 
enthusiasm. Many strange paroxysms have accompanied 
the disorder in France and Scotland. The body has been 
distorted into every conceivable shape, and wild dancing 
and leaping have been kept up to the point of absolute 
exhaustion. 



CHAPTER XXI. 
HEMICRANIA— MIGRAINE. 

This extremely common vasomotor neurosis is, in 
women, usually excited by certain reflex disturbances. 
In some attacks there is contraction of the arterioles on 
the affected side, with consequent anaemia, as shown by 
pallid face, shrunken eye, and dilated pupil. At other 
times the opposite condition of the circulation prevails; 
there is dilatation of the vessels, with a flushed face, in- 
jected conjunctivae, and contracted pupils. 

Prof. Charles L. Dana says that this form of neuralgia 
occurs more often in women than men, in the proportion of 
three to one ; the attacks are most frequent in winter and 
least so in the spring. In America the characteristic form 
is the angeio-spastic type ; but migraine may occur with but 
little vascular change, and there are nervous or sick-head- 
aches which stand halfway between typical migraine and 
ordinary rheumatic or gastric headaches. In most of his 
cases migraine was found to be hereditary, or at least a 
family disease, alternating sometimes with other neuroses, 
especiahy asthma and other neuralgias. Only two of his 
cases seemed to be due to asthenia and refractive errors 
of the eye, and he was not able to convince himself of any 
peculiar nasal or pharyngeal irritations. He adds that 
the idea that migraine is a disease of the sympathetic 
system is one of the old medical superstitions which, with 
the old idea of the sympathetic system, ought to be done 

away with entirely. Indeed it hardly deserves to be dis- 

243 



244 FUNCTIONAL NERVOUS DISORDERS. 

cussed with seriousness. Migraine is a general neurosis 
like epilepsy, showing itself in nervous discharges mainly 
in the area of the fifth. Symptomatically, therefore, it is 
to be spoken of as a form of trigeminal neuralgia whose 
manifestations are strikingly associated with vascular and 
secretory, and sometimes motor, visual, and auditory 
disturbances. 

In speaking of the determination of reflex pains with 
regard to the eye, he says they are produced by asthenopia, 
of which there are four types — 'refractive, accommodative, 
muscular, and neurasthenic. " It appears to be established 
that refractive asthenopia in one eye may give rise to 
migraine. The view that nearly all migraines are .due to 
refractive errors or to imperfection in the muscular ap- 
paratus of the eye is certainly, in my experience, incor- 
rect. It is well to remember that, while eye troubles may 
cause neuralgia, so, on the other hand, neuralgias of the 
fifth may cause eye troubles — such as blepharospasm, 
mydriasis, myosis, and asthenopia (Faucheron, Bee. 
d'Ophthal., March, 1881). Occasionally eye irritation 
causes occipital or fronto-occipital pain, but this does not 
seem to be the rule. Iritis may cause pain felt over one- 
half of the cranium, like a migraine." 

Mallendorf (Virch. Arch., January, 1868) states that in 
his opinion migraine is due to a lack of energy in the 
vasomotor nerves of one of the carotid arteries, with sec- 
ondary relaxation of the vessel and increased flow of blood 
to the brain. Hypersensitiveness of the senses, with 
hyperesthesia of the scalp, nausea, and sometimes vomit- 
ing, are the secondary symptoms. Dimness of vision is 
sometimes present. Mallendorf quotes as proof of his 
theory the fact that the pain is entirely stopped by com- 
pressing the carotid on the side affected, and that when 



HEMICRANIA — MIGRAINE. 245 

the compression is removed the pain returns; also that 
compression of the carotid on the non-affected side in- 
creases the pain. 

The subjects in whom we chiefly meet with migraine 
are women, who from hysteria or ansemia have developed 
a morbid excitability. It is not unfrequently accompanied 
by vomiting and is a most distressing affection. Owing 
to the changes which take place at the menopause, migraine 
usually disappears at this period. 

For the treatment of migraine a variety of agents have 
been used — bromide of potassium in large doses, valerian- 
ate of caffeine, quinine, Fowler's solution, etc. When 
anaemia or chlorosis is present, the preparations of iron 
may be administered with advantage. Outdoor exercise 
and pure air are most valuable adjuncts. Extract of 
ergot has also been recommended, and in certain forms, 
where vascular spasm is present, the inhalation of nitrite 
of amyl is of service. 

I do not believe, however, that the administration of any 
drug is alone capable of effecting any permanent benefit 
in these cases. Much more satisfactory results can be 
obtained by properly regulated outdoor exercise, curative 
gymnastics, pure air, baths, especially sea bathing, to- 
gether with a properly ordered diet and manual treatment. 

I append a few cases of migraine. In all of them it 
will be seen that uterine disease played the chief role as 
an etiological factor. 

Mrs. B. L., age 47, has six children and has had two 
miscarriages. She has migraine, always on the third day 
of menstruation, and night blindness. There is pain in 
the hypogastrium, and also, during menstruation, in the 
back and shoulder. She does not have leucorrhcea. 

Miss C, age 25, has had migraine and headaches for 



246 FUNCTIONAL NERVOUS DISORDERS. 

five or six years; they have been more frequent the last 
six months. Menstruation lasts over a week, and the flow 
is excessive. She has a thick, yellowish leucorrhcea ; pulse 
is weak, appetite poor. She works hard sewing on fura 
with a machine. 

Mrs. M., age 45, lacerated cervix, endometritis. 

Mrs. L., age 30, endometritis. 

Miss O. C, age 38, endometritis, left ovarian pain. 

Mrs. Cr., age 20, endometritis after abortion. 

Mrs. V., age 23, endometritis. 

Mrs. B., age 23, endometritis, lacerated cervix. 

Mrs. T., age 43, menopause. 

Mrs. B., age 24, endometritis and perimetritis, leucor- 
rhcea. 

Miss C, age 25, menorrhagia, leucorrhcea. 

Mrs. B. L., age 47, dysmenorrhoea, occurs on third day; 
also has night blindness. 

Miss N. B., age 24, dysmenorrhoea, inflammation of left 
ovary. 

The following case is of interest because of the alterna- 
tion of two opposite states. 

Miss B., age 26, while living in the country always 
enjoyed perfect health. Since coming to New York, two 
years ago, she has suffered at irregular periods, at first about 
once in two weeks, now usually once and sometimes twice 
a week, from severe attacks of migraine. In the intervals 
between the attacks there is not the slightest pain or dis- 
turbance. There are some slight prodormal symptoms, 
such as soreness of the body and weariness. She awakes 
in the morning suffering with the pain, which manifests 
its greatest intensity in or just above the eye. There is 
no tenderness of the cervical ganglia of the sympathetic. 
Nausea always accompanies the attacks, which usually 
last from six to twelve hours. They are at times of the 
congestive and at others of the anaemic type. When of 
the former, the side of the face is intensely flushed; 
when of the latter, there is extreme pallor of the parts 



HEMICBAOTA — MIGRAINE. 247 

affected. She has an intense craving for sour articles of 
food, and takes large amounts of strong coffee. A care- 
fully regulated diet caused immediate relief, which con- 
tinued so long as L he patient adhered strictly to the 
prescribed dietary and hygienic regimen. 

Migraine might be termed a cramp in the head. It is 
somewhat similar to angina pectoris, in which there is 
often a cramp of the left arm, with coldness, numbness, 
and anaesthesia. 

I have a patient who has a similar cramp in the third 
and fourth toes of the right foot ; it is a reflex from intes- 
tinal indigestion. 

Headache. 

This is the most common of all nervous symptoms de- 
pendent upon indigestion. The indigestion is usually sec- 
ondary and occurs in the liver without any apparent 
symptom except weakness and some anaemia. Worry and 
anxiety are factors in its production, by primarily inter- 
fering with the digestion. 

Hypoxemic Headache. — In this affection, which is often 
toxic, as in cases of malaria, the congestion is constant, 
and may last for weeks if no remedial measures are taken. 
The greater the congestion the more intense the pain. Its 
seat is most frequently the vertex and through the temples. 

In many cases there is considerable fever. The vaso- 
motor conditions in the brain are undoubtedly similar to 
those observed in the face. There we may have cerebral 
flushes, morbid flushing, or on the contrary pallor, due to 
increase or diminution of the blood supply. All of these 
phenomena are dependent upon vasomotor changes. 

Treatment of Headache. — Quinine may be given as a 
tonic, and with iron is useful in relieving this condition. 



248 FUNCTIONAL NERVOUS DISORDERS. 

Tincture of mix vomica, in ten-minim doses, is also a very 
efficacious remedy in removing the indigestion and conse- 
quent headache. In the hypersemic form of headache, 
digitaline granules, in doses of one-sixtieth of a grain, 
twice daily, are often of use. Bathing the head with alco- 
hol or RaspaiPs "Eau Sedatif" gives at times marked 
relief. Bromo-caffeine is a preparation that relieves tem- 
porarily many cases of true migraine. It often seems to 
act like magic, but the effect produced is not lasting. In 
bilious headache, dilute nitro-muriatic acid, five to ten 
minims in water, or a dose of the phosphate of soda will 
often give relief. 

Congestive Headache. — Mrs. S., a widow, age 42, has 
for a week past had constant and severe headache, worse 
at night, due to the worry and care of a large boarding- 
house. The pain affects the entire head, more especially 
the top and back. The urine has a specific gravity of 1.014, 
is of light color, and is normal in quantity; it contains 
neither albumin nor phosphates. 

The patient is languid, weak, and intensely drowsy, and 
usually has a great thirst, due to chronic gastric catarrh. 

The headaches are in this case of gastric and hepatic 
origin, and are frequently the result of financial worry. 
Under a lessening of the mental strain, and with happier 
surroundings, her condition has markedly improved. 

Migraine, Congestive Type, Due to Chronic Intersti- 
tial Nephritis. — Mrs. M., age 55, stout, has slight 
asthma. Examination of the urine shows albumin. She 
is careful in her diet. She caught a severe cold, which 
manifested itself principally by an attack of severe mi- 
graine that was relieved only by the persistent use of 
large hypodermic injections of morphine. It lasted about 
three days. She had a similar attack before, which lasted 
so long that the diagnosis of the attending physician was 
"inflammation of the meninges of the brain." 



HEMIC RANI A — MIGRAINE. 249 

Migraine and Asthmatic Bronchitis Dependent upon 
Indigestion, — Miss S. V., age 40, has asthmatic bron- 
chitis of long standing. Many of her relations have died 
of phthisis. She is now suffering from severe migraine 
in right temple, which frequently recurs. That it is of a 
congestive type is indicated by the throbbing and enlarge- 
ment of the carotid artery, and from attacks of hemor- 
rhage on the same side of the nose. For a year past she 
has been living entirely upon vegetable food, of which she 
has been taking excessive quantities. She has an especial 
craving for fresh bread. She dislikes meat. A simple 
dietary was prescribed, consisting of broiled minced beef, 
stale bread, hot water, etc., as well as a tonic regimen, 
and she states that from the very first she began to im- 
prove and to develop an appetite for meat. She now likes 
it very much, and considers it a great luxury. Breathing 
has become easier and the asthma has entirely disap- 
peared. Her voice, which was almost entirely lost, has 
returned. She was supposed by her friends to be a case 
of chronic phthisis, but she is now, after three days' treat- 
ment, vastly improved in health, and considers herself 
quite well. 

Hemicrania, Dependent upon Maldigestion and upon 
Irritation from the Left Ovary. — Miss J. W., age 28, is a 
blonde, unmarried, well educated and refined, with much 
strength of character ; she has every comfort. When I first 
saw her, in October, 1887, she was suffering from hemi- 
crania. The pain, which was of a very severe character, 
was localized in a small spot on the right side of the head 
near the vertex. The attack was usually so severe as to 
cause fainting; she complained of excruciating pain in the 
left ovary, and felt as if she might lose her reason. Octo- 
ber 26th, 1890, while suffering, she took twenty-five grains 
of bromide of potassium, which, she thought, started the 
pain in the left ovary, and this was followed by a sense of 
suffocation, a globus hystericus, and a hystero-epileptic 
attack. When I saw her she was rigid and seemed uncon- 
scious ; she was surrounded by her friends, who were much 



250 FUNCTIONAL NERVOUS DISORDERS. 

alarmed, thinking that perhaps she had poisoned herself 
with the medicine. She seemed unable to speak, but 
after taking a teaspoonful or two of brandy and water she 
became completely conscious, but could not open her fin- 
gers, which were tightly closed. After a little time the 
contractions relaxed and her hands opened. She com- 
plained of creeping sensations all over her body, and would 
continually clasp and unclasp her fingers. She had the 
usual symptoms of migraine, a tendency to which she had 
inherited from her mother. Miss W. is especially liable 
to have these attacks in the early spring, and when for 
any length of time she has been confined to the house with- 
out fresh air. They are also brought on by overwork. 
She has no post-nasal catarrh nor eye trouble as causative 
factors. 

Bromide of caffeine in large doses gave a temporary 
relief. A short sea voyage to a southern port was recom- 
mended, and was productive of marked benefit by greatly 
improving her general health. 

Migrainous Headache as a Gastric Neurosis. — Mrs. 
D., age 38, has had two children. Whenever there is an 
acid condition of the stomach she suffers from most severe 
migrainous headaches, alternately in either temple. She 
has also severe pains over the greater curvature of the 
stomach. There is a great amount of flatulence and much 
intestinal colic. While pregnant she is unable to eat meat 
or other solid food in the morning ; she takes merely coffee, 
and during the day consumes a good deal of tea. She 
takes only two meals daily, one at 11 a.m., and the other 
at 6 p.m. She has a craving for salt meats, for vegetables, 
especially potatoes, and for fruit. 

Under a change of diet there was a marked alleviation 
of her symptoms. 

In many of these cases there is a tendency toward 
chronic nephritis. 



CHAPTER XXII. 

THERAPEUTICS. 

"In other cases special treatment remains ineffectual, until by 
generally strengthening treatment the vital energies have increased 
and the process of recuperation, latent in the organism, is again 
aroused to life. " — Gustaf Zander. 

In the treatment of these neurasthenic conditions the 
most important factor to be considered is vitality, or re- 
sistance to disease; it should be carefully studied and 
every effort made to sustain and augment it. Often by 
inspection alone the skilful physician can determine quite 
accurately the vital resistance of the patient. Some indi- 
viduals are of "good timber," while others can only be 
compared to punk. The first seem to have an invincible 
power of resistance to the effects of starvation, accident, or 
disease, while the second will succumb to the most trilling 
ailment or casualty. Many thin and apparently delicate 
persons easily resist deleterious influences, and if affected 
quickly recover; while some stout, and to all appearances 
strong individuals, can, under the same conditions, barely 
exist, so weak is their vital resistance. Those of the first 
class are endowed at birth with this force of constitution, 
while the portion of the others is inherited weakness. 

Fear, as is well known, is a great factor in the produc- 
tion of disease; it depresses the force of the system, thus 
weakening the vital resistance. It causes cold sweats, 

diarrhoea, excessive urination, disordered perspiration, 

251 



252 FUNCTIONAL NERVOUS DISORDERS. 

palpitation of the heart, and jaundice. By this depressing 
action upon the vital functions, it favors the onset of the 
disease and increases its malignity when present. This 
is commonly seen in epidemics, such as cholera, typhus 
fever, or small-pox, fear causing the disease in many who 
would otherwise escape. 

The passions of the mind and soul have as important 
a place as factors in the production of disease as the septic 
poisons and the various morbific bacteria, and they are of 
special importance in these hysterical, neurotic affections. 

When a woman is in the full vigor of health, all her 
functions are properly regulated and are always the same. 
The heart beat is slow, full, and strong ; the respiration is 
natural and unembarrassed; the nervous system is per- 
fectly in accord with the rest of the body. When, how- 
ever, weakness supervenes, all sorts of aberrations in in- 
finite variety occur. As much of the disease from which 
nervous women suffer is of bacteriological origin, the pre- 
vention of catarrhal states of the digestive, respiratory, or 
genital tracts by internal or tissue asepsis (as I term it) is 
of vast importance. 

The value of prophylaxis should be more appreciated 
than it is in our daily practical work. I do not under- 
estimate the importance of symptomatic treatment as our 
routine practice demands it, but we should not, as we 
are prone to do, confine ourselves to dealing exclusively 
with symptoms which in most cases arise from the basic 
malady. Our conception of disease must be broader. By 
considering the basic malady, we are better prepared to 
meet the demands of modern prophylaxis. The physician 
will have to deal with the pathological tendency to non- 
bacteriological affections, such as retarded growth, anse- 
mia, cardiac weakness, contracted chest, catarrhal con- 



THERAPEUTICS. 253 

ditions, etc. , as well as affections of microbic origin, with 
which I intend to deal briefly. In these days hereditary 
predisposition is no longer regarded from a fatalistic 
standpoint, a knowledge of hygiene and prophylaxis giv- 
ing us the means to counteract it ; the highest art of the 
physician lies in applying this knowledge to individual 
needs, preventing overexertion, strengthening weakened 
organs, and restoring tone to the system. 

Internal sterilization presents many difficulties not en- 
countered by the surgeon, whose treatment can be local- 
ized. Internal or tissue asepsis is a complicated matter, 
and in the majority of cases we have to adopt a systema- 
tic constitutional treatment. Measures which vitalize the 
organs, promote circulation, metabolism, and tissue change, 
and so contribute to the building up of the whole system, 
will have to be adopted, and will consist of a proper die- 
tary, curative exercise, internal and external hydrotherapy, 
electro-therapy, change of climate, or appropriate drugs, 
according to the indications. I believe that medicines are 
more effective in a patient whose vitality has been in- 
creased than in one whose vitality is low. The internal 
use of water is to my mind a valuable means of restoring 
tone. (See my article upon the subject in the Medical 
Record for November, 1895.) Dr. Otto Leichtenstern 
('''Handbook of General Therapeutics," Ziemssen, Vol. 
IV., New York, 1885) says that the effects of abundant 
water drinking are in close connection with the quantity 
and temperature of the water taken in. The effect of the 
drinking of cold water is a lowering of the bodily temper- 
ature, and if the stomach is empty it leaves it very quickly. 
The water absorbed through the mucous membrane of the 
stomach and intestines is in large part taken up by the 
veins, notably the vena portce, as well as by the lymphat- 



254 FUNCTIONAL NERVOUS DISORDERS. 

ics. There is no diminution of the specific gravity of the 
blood, as has been shown by the experiments of Magendie, 
Nasse, Denis and Leichtenstern, nor is any increase of 
water observed after copious water drinking. This is due 
to the fact that as soon as the water is absorbed from the 
stomach and intestines it begins to be excreted in the urine. 
Thus a large amount of water can pass through the body 
in a short time without causing any demonstrable increase 
of the amount of water in the blood. The water distrib- 
utes itself not only to the blood current but also to the 
fluids of the tissues in all parts of the body. Leichten- 
stern says that we have in copious water drinking, a 
means of subjecting the whole system to a powerful wash- 
ing out, and a consequence of this is the temporary in- 
creased excretion of certain products of the tissue changes. 
He says that although, so far as he knows, " no thorough 
experiments, not open to exception,' have as yet been made 
on the action of copious water drinking in conversion 
of tissue, yet experiments up to the present time warrant 
the following conclusion: . . . The greater amount of 
diuresis after drinking large quantities of water pro- 
duces a quantitative increase of the excretion of urea, 
of chloride of sodium, of phosphoric and of sulphuric 
acids." It has also been shown that the amount of uric 
acid is diminished by copious water drinking. Investiga- 
tors have found an increase in urea, and the increase of 
salts in the urine has been proved by the experiments of 
half a dozen different observers. Without doubt the in- 
creased quantity of water which permeates the tissues 
favors the decomposition of the waste albumin, and thus 
augments the excretion of urea ; there may be also a more 
rapid removal of the urea already formed, but the major- 
ity of authors believes the increased conversion of the albu- 



THERAPEUTICS. 255 

minates to be the main factor. New and thorough experi- 
ments upon this subject may be desirable, but for my part, 
I do not consider them to be necessary. Leichtenstern still 
further says : " Unquestionably, numberless cures owe more 
of their efficacy, in diseases, to the diuretic and washing- 
out effect of the water drunk in increased quantity than 
to the salts and gases dissolved in it. We make the most 
extensive use of this washing-out power of water in thera- 
peutics. Copious water drinking, may, under proper cir- 
cumstances, be used efficaciously in many cases : when it 
is the object to bring exudations to absorption, to wash 
out accumulated particles of bile from the blood and from 
the tissues, to increase the secretion of bile and the press- 
ure of the secreted bile; when it is the object to remove 
certain poisons which have got into the system, or to wash 
out blocked up urinary tubuli. In all these cases where 
large quantities of water are employed, simple water (I 
include here distilled water with any addition to make it 
palatable) is to be preferred to mineral waters or to solu- 
tions of salts. And as water in large quantities is better 
borne by the stomach taken warm than cold, the use of 
the former is preferable, and besides that it is more rapidly 
diffused." " It is known that other excretions besides that 
of urine are influenced by copious water drinking. Leh- 
man observed in the horse an increased secretion of the 
parotid, the specific gravity of which at the same time 
became lighter; and Weinman witnessed a considerable 
increase in the pancreatic secretion of the animal experi- 
mented upon, after a large supply of water. Bidder, 
Schmidt, Nasse, Arnold, found the secretion of bile in- 
creased after copious draughts of water, the specific grav- 
ity of bile diminished, and the amount of solid matter 
excreted through it increased. 



256 FUNCTIONAL NERVOUS DISORDERS. 

" Copious Water Drinking Increases the Sensible and 
Insensible Transpiration of the Skin, in Health and in 
Many Diseases. This has been proved by innumerable 
experiments which have been made by Ferber, Mosler, 
Weyrich, and repeated in Niemeyer's clinic." 

Where a small quantity of chloride of sodium is con- 
tained in the water, as at salt springs, the secretion of the 
gastric, juice, which is strongly antiseptic, is stimulated 
and increased; the formation of peptone is also favored, 
and reflexly the salt excites the peristaltic action of the 
stomach and intestines, and thus furthers the removal of 
any stagnating contents which would otherwise remain for 
a longer time in the digestive canal. Salt has also a slight 
diuretic action. With a slight increase of the supply of 
chloride of sodium, there is an increased excretion of nitro- 
gen through the urine. Yoit says that this action of chlo- 
ride of sodium is caused by its increasing the celerity of 
diffusion of the current of fluids through the tissues, so 
that larger amounts of the circulating albumin are exposed 
to the breaking-up powers of the cells. The practitioners 
at Bath, England, according to Leichtenstern "make the 
fullest use of this important physiological fact, and of its 
explanation, in expounding the curative effects of the salt 
waters, as well as in laying down indications for their use. 
The salt waters, they say, 'powerfully excite the conver- 
sion of tissue' ; hence their favorable operation in 'general 
plethora,' 'in over-nutrition,' in obesity, etc. 

" While the salt waters promote the circulation of the 
fluids also through pathological products, plastic and 
other formations, they loosen their structure, carry away 
their albuminates, and favor their combustion ; along with 
this, fat is formed in the pathological products, which now 
can easily be absorbed. On this is based the theory of the 



THERAPEUTICS. 257 

curative effects of salt water in scrofulosis, with its many 
exudations and hyperplasias of the glands; on this rests 
the theoretical indication for the use of these waters in the 
most varied exudations of different organs, especially in 
chronic infarction of the uterus, in chronic exudations of 
the pelvis, in peri- and para-metritis, etc. . . . 

" Voit announces as a further property of salt, that it 
influences the solubility and the diffusibility of albuminous 
matters. On these no doubt correct conclusions of the 
physiologist, balneotherapists ground the important thera- 
peutic effects of the salt waters. To use their modes of 
expression, salt waters 'stimulate and heighten the plastic 
activity of the organism, facilitate the formation of cells, 
increase the number of blood corpuscles, lower the amount 
of water and of albumin of the blood,' and as these waters, 
as we said above, at the same time increase the combustion 
of albuminates, they should possess the remarkable property 
of regenerating the whole organism, of purifying it of its 
injurious dross, and of renewing its youth. The problem 
of Medea would thus be solved in tho simplest way, by 
salt waters. Diruf pointed out as a fact 'which could not 
be sufficiently proclaimed,' in a therapeutical point of 
view, that a 'moderately increased supply of chloride of 
sodium is able, under certain conditions, to induce, along 
with the accelerated conversion of nitrogenous tissues, an 
excess of formative over removing action in the system, 
and in other cases to reverse the process.' Certainly a 
very convenient if not a very clear theory for explaining 
the efficacy of salt waters in the most different forms of 
disease, a fact which cannot be empirically gainsaid. 

" Chloride of sodium is said to increase 'the secretion of 
various mucous surfaces,' and especially that of the organs 

of respiration. It is said to act as an 'anticatarrhal.' as a 

17 



258 FUNCTIONAL NERVOUS DISORDERS. 

'solvent of mucus' to 'regulate the nutritive condition of 
the affected mucous membrane,' etc. Hence the recom- 
mendation of these waters in catarrh of the respiratory 
organs; the lion's share of the empirically proved efficacy 
of these waters, in such affections, is no doubt to be as- 
cribed to their warmth." 

Anything which destroys the micro-organisms that are 
detrimental to the bodily health is an antiseptic ; therefore 
dietetic treatment in its broadest sense, which includes 
curative exercise, hydrotherapy, etc., as well as the scien- 
tific selection and preparation of food, is antiseptic, as it 
enhances the vitality and bodily resistance to disease bac- 
teria, by increasing the germicidal power of the blood. 

As many nervous women are tuberculous, or are from 
their anaemic condition in danger of contracting tuber- 
culosis, a few words upon its prophylaxis will not be out 
of place. 

Up to about twelve years ago the treatment of tubercu- 
losis was entirely empirical. In 1882 Robert Koch, of 
Berlin, for the first time proved beyond a doubt that this 
disease was caused by bacilli which, on account of their 
peculiar behavior toward strong acid, could be positively 
diagnosed in every case of tuberculosis. All subsequent 
experiments have shown that Koch's statements were per- 
fectly correct, and to-day we can say that there is no 
tuberculosis without the presence of these characteristic 
tubercle bacilli. It is true that at the commencement of 
the affection it is not always easy to find the bacilli, but 
careful examination of the sputa at different times will 
invariably show their presence in a greater or less degree. 

Tuberculosis' may start very slowly and gradually; so 
much so that, physically, no characteristic symptoms of 
the disease may be found, but examination of the sputa 



THERAPEUTICS. 259 

will already, at this early period, demonstrate the presence 
of the bacilli. In every case of cough which has lasted 
for some time the physician should invariably make it the 
rule to examine the sputum, whether he suspects tuber- 
culosis or not. If this is done, and only then, can we ex- 
pect better results from our treatment than we have 
heretofore achieved. 

In a large number of cases bacilli may be found in the 
s^>uta long before there are any well-marked physical signs, 
so that their detection will afford the first clew to the pa- 
tient's malady. Even at the present day some physicians 
claim that there are cases of phthisis without the presence 
of tubercle bacilli. The trouble with them will, however, 
simply lie in the meaning of the word "phthisis," as some 
will call a chronic catarrhal pneumonia fibroid phthisis. 
That this is not tuberculosis need hardly be mentioned. 

Another mistake which is often made is to call tubercle 
bacilli the sole cause of tuberculous infection, since tubercu- 
losis will never affect people with good constitutions, but 
only those with poor, broken-down constitutions. People 
with good constitutions may continually inhale the bacilli 
without any bad effects whatever. The human body 
may be in a condition that is termed health, and still 
pathogenic bacteria may be present; these are kept in 
abeyance by the defensive action of the blood -serum and 
leucocytes. It is this repressive power of the blood that 
keeps them from propagating and doing injury to the 
economy. 

Bacteria often seem to be destroyed by phagocytosis. 
There is an antibacterial property in the tissues, fluids, 
and secretions of the body, and these are natural defences 
against the growth of micro-organisms. The contact of 
germs does not lead to infection unless the material is 



260 FUNCTIONAL NERVOUS DISORDERS. 

present to favor their development. One of these causes is 
a poor or broken-down constitution. When this is present 
any existing bacteria will multiply and thrive. Another 
cause is the presence of the products of fermentation, in- 
flammatory exudates, and diminished blood-supply. If 
the constitution is improved, and the pabulum upon which 
the bacteria thrive removed or its formation stopped, their 
development is hindered or entirely checked, and thus the 
severer forms of inflammation are obviated. A plant can- 
not grow upon a rock or thrive upon barren soil, and so it 
is with all forms of life, even the minute organisms. The 
substances upon the surfaces of wounds which cause the 
development of micro-organisms and thus produce infec- 
tion, are readily removed by the most important and chief 
means for all sterilization; that is, the mechanical purifi- 
cation by washing and cleansing with water. Why 
should not the substances in the interior of the organism, 
which are the pabulum for bacterial development, also be 
removed, at least to a great extent, through the channels 
of the body which terminate directly in the emunctory 
organs? It is quite possible that the sewerage system of 
the tissues, when properly stimulated in the work of elimi- 
nation, will carry along in its circulation much of the 
material which causes infection, and thus produce what 
might be termed an internal sterilization or asepsis. Many 
seem to think that, after a germ has once entered the 
body, it cannot be removed until it is thoroughly digested; 
but why should not cleanliness, applied to the internal 
organs whenever possible, aid in the elimination of the 
micro-organisms? If we cleanse the oral cavit} r daily, we 
may just as well go farther and cleanse the stomach, intes- 
tines, and the tissues. Tubercle and other bacilli usually 
enter the organism by the canals and ducts which commu- 



THERAPEUTICS. 261 

nicate with the outside of the body. The alimentary canal 
in many cases is the primary means of entrance. The infec- 
tion then extends by following various routes. The bacilli 
are carried along the lymphatic channels into the tissues 
or lymphatic glands. These glands appear to have the 
power of arresting the infection, for a time at least, before 
it finally passes into the blood, and this would seem to be 
the critical period in the treatment. Pure or sterilized 
granite or trap-rock waters taken hot in sufficient quanti- 
ties and at proper times, combined with systematic mus- 
cular exercise, hot baths, and massage, will certainly help 
to cleanse out the tissues of the bod3 T . 

We ma}' furthermore take advantage of the bactericidal 
properties of the blood serum. This protective property of 
nature is best enhanced by enriching the blood by the 
various means within our power, one of the most important 
of which is scientific dieting. The ordinary diet of indi- 
viduals is often extremely bad, the place of wholesome food 
being taken by sweets and stimulants, such as sugar, pas- 
try, tea, coffee, and alcoholic drinks, so that not infre- 
quently patients will grow weak and the constitution will 
suffer simply on account of the deprivation of proper 
nourishment. 

The plan of treatment, which I have already described 
in the New York Medical Journal for October, 1894:, 
consists in giving at rather frequent intervals a consi oper- 
able quantity of carefully roasted or broiled beef or mut- 
ton, raw eggs, stale bread, butter, sterilized milk, and 
vegetables. After a few days of treatment the meat 
should not be less in amount than a pound a day, and the 
quantity of bread and vegetables should be, if possible, 
somewhat larger. When there is a disgust for the meat 
diet the stomach needs special treatment, for a short time 



202 VV NATIONAL NERVOUS DISORDERS. 

only, by the addition of a digestant, such as dilute hydro- 
chloric acid and hot water to remove irritations. 

Tuberculosis is the great destroyer, as it is the most 
frequent of all fatal diseases; and malnutrition and de- 
fective elimination, which will sooner or later break down 
the constitution, are at its foundation. It is estimated 
that in the United States nearly five hundred individuals 
die of this disease every twenty-four hours. Its extreme 
prevalence and destructiveness have urged physicians in 
all countries to make strenuous efforts for its prevention 
and extermination. 

It has been mentioned in this work a number of times 
that constitution is one of the most important points in 
the development of tuberculosis. It may be well to show 
how the constitution of the patient can easily be deter- 
mined under the microscope. Not only may this be done 
by the colorless blood corpuscles, but also by the inflam- 
matory pus corpuscles which we will invariably find pres- 
ent in every sputum in which there is an inflammation of 
any kind whatever. 

These views were first announced by Carl Heitzmann in 
1879, and have since been corroborated by a number of 
independent observers both here and abroad. They are 
the following: The amount of living matter within a 
limited bulk of a corpuscle varies greatly in different in- 
dividuals. It is obvious that what is called a healthy or 
vigorous constitution is based upon a large amount of liv- 
ing matter in the body, the new growth of which in 
morbid processes is very lively; while a phthisical or so- 
called scrofulous diathesis must be caused by a relatively 
small amount of living matter, the new growth of which 
is scanty in morbid processes. In other words, a corpuscle 
will exhibit coarse granulation, or it will be almost homo- 



THERAPEUTICS. 263 

geneous-looking, under the microscope, owing to the large 
amount of living matter in strong individuals of good 
constitution; while a corpuscle taken from a person with 
a weak or tuberculous constitution will be pale and finely 
granular, as but little living matter is present in it. In a 
given case, therefore, the more numerous the coarsely 
granular pus corpuscles or colorless blood corpuscles pres- 
ent, the better the constitution; and, on the other hand, 
the more abundant the finely granular ones, the worse the 
constitution; and when the corpuscles become broken up 
and disintegrated we can say that death is not far distant. 
As long, then, as we find the coarsely granular, homogene- 
ous corpuscles predominating, so long there will be no 
danger of the individual contracting tuberculosis; and 
when upon examination we find that the corpuscles do not 
contain a sufficient amount of living matter, that is, they 
have become more or less finely granular, we should at 
once resort to all possible means to increase the living 
matter, as otherwise tuberculosis may set in at any time. 

Klebs, in the Journal of the American Medical Asso- 
ciation for October 12th, 1895, says, in speaking of anti- 
phthisin in tuberculous affections of children : 

" It would certainly be unreasonable to demand that this 
remedy, which has a specific germicidal effect upon the 
tubercle bacillus only, shall also remove and cause the cure 
of pathologic changes which result remotely from the 
primary cause, and, more unreasonable still, that the rem- 
edy shall also favorably influence and cure complications 
which, like infection with other pathogenic germs, have 
no relation to tuberculosis at all, more than that they may 
be associated in the same patient. 

" In all such cases it is necessary to remove the compli- 
cations by other treatment, either before or in conjunction 



264 FUNCTIONAL NERVOUS DISORDERS. 

with the application of the specific remedy ; but the final 
results are determined by the importance and curability 
of such attending pathologic processes. 

" We see, thus, that the use of a specific germicidal rem- 
edy can only be fully effective when the disease is still 
uncomplicated by secondary degenerations, and is free 
from complications which, unfortunately, are present in 
most cases of tuberculous disease as they come under our 
notice; there are, however, not a few cases of purely 
tuberculous affections in an early stage in which the results 
of specific medication are highly satisfactory. . . . For 
these, as in all other therapeutic efforts, the only unavoid- 
able condition is that the organism itself shall still have 
the power to use and appropriate the introduced curative 
substance; for under no circumstances can we otherwise 
conceive the cure of disease than that the living organism 
must, itself, take an active part in its removal." 

In closing his paper he says : " Finally, I wish to point 
out that, in all tuberculous affections, the same as in many 
other severe and serious diseases, their treatment in hos- 
pitals or special institutions offers great advantages over 
that of private practice." 

The means of improving the general constitution have 
already been partly stated above, but I wish to dwell espe- 
cially upon the good results obtained from regular syste- 
matic physical exercise. The medical profession has 
always deemed physical education a hygienic measure of 
the greatest importance. 

The well-known Dr. Gustaf Zander says: "Experience 
having shown that regular muscular exercises, gradually 
made more strenuous, not only develop and strengthen the 
muscles, but promote the removal of pathological changes 
in the tissues, give tone to the nervous system, and vitalize 



THERAPEUTICS. 265 

the circulation of the blood and lymph and the activity 
of many organs, it is natural that such exercises should be 
included among therapeutic agents. For this purpose 
there was, however, requisite the power to execute these 
exercises according to physiological laws, and to modify 
their action, like that of any other therapeutic agent, ac- 
cording to the needs of each individual case." Therefore 
those persons who take up physical culture without a com- 
petent medical instructor may do themselves serious in- 
jury, or at least obtain no special benefit from it, by 
attempting methods unsuited to their physical condition, 
or neglecting to carry out a practical system in a proper 
manner. Physical exercise at home soon becomes a mat- 
ter of drudgery to the weak and poorly developed, who 
especially require it. As the interest is lost, it is neglected 
or carried out in a desultory manner, and thus the beneficial 
results are not obtained. Under a competent medical in- 
structor there is, along with sustained interest, a rapid 
and harmonious development of those portions of the body 
which most need it. Hysterical women and" neurasthenic 
patients of both sexes especially, and also children, should 
not be allowed to take this exercise at home, as they per- 
form it without system, overdoing it one day and entirely 
neglecting it the next. Very judicious passive exercise 
should begin the treatment, which should be gradually in- 
creased; at the same time they are under control, which 
strengthens their will power, and they have to obey instead 
of ordering others about. 

The indications and contraindications for muscular exer- 
cise should be carefully determined. Exercise does not do 
everything; sometimes rest and drugs are needed. Ther- 
apeutics always belong to the physician, and not to the 
layman. The massage following the bath is something 



266 FUNCTIONAL NERVOUS DISORDERS. 

difficult, and with many impossible, to obtain at home, 
and it should not be in the hands of laymen. In anaemic, 
nervous women with bad carriage, to overcome the de- 
formity of round shoulders, the muscles of the back and 
abdomen must be systematically exercised and strength- 
ened. The flattening of the chest, which is the result of 
the shoulders falling forward, tends to the production of 
lung disease, by interfering with their complete expansion. 
To overcome this deformity, the patient should stand with 
head erect, with the abdomen drawn back and chest pro- 
jecting, and then forcibly draw the shoulders back as far 
as possible, as if to make the shoulder-blades meet. This 
should be performed from ten to fifty times daily ; in fact, 
at frequent intervals during the day, whether exercising 
or not. All shoulder braces are useless for this purpose. 

For broadening the chest, assume the erect posture. 
The movement should be as follows: Starting with the 
hands in front of the hips, force them by a lateral and 
backward movement as high above and behind the head 
as possible. 'A modification of this movement, which is 
easier and more graceful, consists in starting with the 
arms extended behind the back, and letting them go up 
alternately as far as possible, while keeping the elbows 
perfectly rigid. All these exercises are best performed 
with light dumbbells, from two to five pounds in weight. 
This last movement is of especial advantage in drawing 
upward and outward the sides of the chest, thus increas- 
ing its capacity. 

Another beneficial exercise for deepening the chest and 
straightening the shoulders, is to stand with arms project- 
ing straight forward, elbows perfectly stiff. Let the arms 
go straight backward as far as they will, on a level with 
the shoulders. Meanwhile, the erect posture must be 



THERAPEUTICS. 267 

maintained — head erect, chest projecting, and chin drawn 
in. This is a splendid exercise for increasing the lung 
capacity. These movements should be repeated until the 
particular muscles involved become fatigued, when the 
instructor will change them and bring into use another set 
of muscles, and so on. The respiration should be full and 
free, and the air perfectly pure. A system of this kind, 
carried out in a scientific manner, strengthens not only the 
muscles, but all the vital functions, and is adapted not 
only to adults, but to children as well. Respiration and 
digestion are improved with the increase of vitality, and 
the elimination of the waste of the body is greatly en- 
hanced. By specific exercises the chest cavity is broad- 
ened and deepened, and the chest expansion and manner 
of breathing greatly improved and permanently benefited. 
Not only the lungs, but the brain and nervous system are 
powerfully influenced by systematic bodily exercise. The 
brain will accomplish only imperfect results if the body is 
not in a state of health. 

Everywhere we see the lack of physical exercise; men, 
women, and children Avith narrow chests, pale, emaciated 
faces, and a general look of exhaustion are met daily. If 
extreme leanness is not present, obesity produces ugliness 
of the human form. A comely, erect, well-formed body 
is much less common. Judicious systematic muscular ex- 
ercise and a proper dietary give vigor, activity, and cour-. 
age, both mental and physical. 

The supply of oxygen is greatly increased by deep, full 
inhalations in the open air, thus increasing the lung capac- 
ity, purifying the blood, and strengthening the nervous 
system. The temperature of the body is equalized as a 
result of ttie muscular exercise and the eliminative sys- 
tem stimulated to increased activity, while digestion and 



268 FUNCTIONAL NERVOUS DISORDERS. 

assimilation are brought to their highest point of effi- 
ciency. 

I desire to refer at this point to Dr. Wischnewetzky, 
who first established a complete median ico-therapeutic 
Zander institute in this country, and directed it for five 
years, but at present has no connection with the institu- 
tion. He says in " Contributions to Mechanico-Therapeu- 
tics and Orthopaedics," Vol. I., No. 2: " By affording a 
basis for the scientific medical application and discussion 
of mechanico-therapeutics, Dr. Zander has placed the sub- 
ject above the level of a peculiarly Swedish method, and 
has enriched the science of medicine. Hence, although 
Dr. Zander is a Swedish physician, his method can no 
more be called Swedish than pathological anatomy, which 
has been so effectively promoted in Germany, is German, 
or antiseptic surgery English, because Joseph Lister was 
born in England. . . . 

" The physician has here forced the mechanical progress 
of our age into the service of medicine for the solution of 
problems of an anatomical nature. He enables us to exer- 
cise any given group of muscles strictly in accordance with 
the laws of physiology ; to exclude any other group at will ; 
to determine which groups are called into action, and to 
what extent in every movement made. 

"By subjecting to localization, measurement, and con- 
trol a therapeutic agent which, for want of these qualifica- 
tions, was not susceptible of rigid scrutiny, Dr. Zander 
has created the basis for the use of mechanical treatment 
as an agent capable of fulfilling all the conditions imposed 
by the most exigent scientific criticism. 

" The importance of systematically organized muscular 
exercise is no longer a subject of debate. The question 
always open for the conscientious physician is : ' How 



THERAPEUTICS. 209 

shall such treatment be administered without risk of harm 
and with all the benefit which is in many cases obtainable 
from it?'" 

Alimentation and Hygiene. 

Correct alimentation in nervous derangements is most 
important. To secure healthy, rich blood, proper food 
and good digestion are necessary. In many patients suf- 
fering from functional nervous disorders there may be a 
depraved appetite present, and in other cases the appetite 
may be entirely absent, so that the amount of nourishment 
obtained by these patients, if they are left to follow their own 
inclinations, will be very small, although they may partake 
of large quantities of indigestible and unwholesome food. 

Indigestion is a common causative factor in the produc- 
tion of functional nervous disorders. Those who are en- 
gaged in intellectual work, such as journalists, lawyers, 
physicians, and other professional men who lead seden- 
tary lives, are most likely to have functional disorders as 
a result of indigestion. But indigestion is most common 
in nervous women. Conditions of high pressure and men- 
tal strain, such as striving for financial and social success, 
cause the overtaxed and exhausted stomach to rebel. 
Worry and anxiety cause a condition of mental depres- 
sion : the patient is distrustful of herself and of the future, 
and, neglecting exercise, mopes at home without enlivening 
distraction, the result being an impaired digestion and a 
lowered state of the nervous system. These women, as a 
result of their imperfect digestion, are almost always irri- 
table and find difficulty in exercising sufficient self-control 
to make life pleasant to themselves and their friends. In 
many of these cases of indigestion and nervousness there 
is a condition of extreme lethargy, while in others the 



270 FUNCTIONAL NERVOUS DISORDERS. 

opposite condition of sleeplessness is frequently present. 
Women of this class, as a rule, when they are in this con- 
dition eat a sufficiency of easily digested food, but the 
catarrhal state of the mucous membrane of the stomach 
and intestines interferes with its absorption. It not only 
causes interference with absorption, but in many cases it 
causes decomposition and promotes the development of 
poisonous products. These, when absorbed into the sys- 
tem, irritate and depress the patient and bring on the ner- 
vous manifestations. So weak, languid, and easily 
fatigued do the patients become, that they are unable to 
take the exercise necessary to rid the system of its waste- 
ash through the emunctories of the body. The excretion 
of perspiration is insufficient in amount, and there is usu- 
ally chronic constipation interrupted by intercurrent at- 
tacks of diarrhoea. 

It is well known that some headaches are dependent 
upon constipation, and that they are often relieved by 
cathartic medication. Irritation of the vasomotor nerves 
of the head from disturbances of the stomach or intestines 
is a common condition. Constipation causes reflexly a 
sensation of congestion, and the frontal congestive head- 
ache is the result of the indigestion and constipation, act- 
ing reflexly or by direct absorption in the intestines. In 
health there is a blessed unconsciousness of the very exist- 
ence of a stomach, but let dyspepsia be present and the 
patient can think of little else. A perfect digestion gives 
great energy; the blood circulates normally through the 
brain and the nervous system, work, mental or physical, 
is a pleasure, and life seems well worth living. But the 
dyspeptic knows nothing of the joys of existence. A 
shattered nervous system is all that occupies her time and 
thoughts, and by this constant introspection are brought 



THERAPEUTICS. 271 

about the various conditions of neurasthenia, hysteria, and 
other complaints which we have been studying. The 
importance of dietetic treatment will thus be evident. It 
is essential that a definite plan be pursued, and there are 
some important points which we must ever keep in mind. 
We must procure an effective elimination of all the waste 
products of the body. First, we must prepare the diges- 
tive tract and the tissues of the body to receive and as- 
similate the nutriment, and then we must select the most 
nutritious food and so prepare it that it will be readily 
assimilated. We must remember f to treat the whole sys- 
tem, which is in a pathological condition. The most 
rational method of securing elimination through all the 
channels of the body is by stimulating the activity of all 
the emunctories by the ingestion of a large quantity of hot 
water, and by hot sponge baths, followed by a vigorous 
rubbing of the skin. This plan of treatment, to be effec- 
tive, must be systematically carried out, and both physician 
and patient must steadfastly avoid that complete depend- 
ence on drugs which converts the wisest method of treat- 
ment into blind empiricism. 

The causation of a disease should be carefully studied, 
and then by treating the diathesis the consequent disease 
can be prevented or removed. Most of these diseases 
depend for their propagation upon defects of nutrition. 
These being removed, the disorder often disappears. We 
must remove the cause, otherwise the disease will persist 
in spite of all treatment, and to do this a perfectly clear 
diagnosis is necessary. It is the bringing up of the vital- 
ity of the patient that leads to recovery, as a lowering of 
the vitality is the first factor in producing disease. 
Whenever there is vital energy there is resistance to dis- 
ease. It is a well-known fact that Nature has the power 



272 FUNCTIONAL NERVOUS DISORDERS. 

to cure in most cases if we give her the materials to work 
with, and at the same time stimulate the activity of the 
emunctories sufficiently to remove the poisonous waste. 

The diet for neurotic patients must be a scientific one, 
based on a knowledge of what the different kinds of food 
do for the organism. We must provide, first, for the 
oxidation and elimination of waste products, and, secondly, 
for scientific alimenation with readily absorbed and easily 
assimilated nutritive materials of the highest grade. 
There are many factors necessary for the successful treat- 
ment of the neuroses — rest, mental and physical, pure dry 
air, gentle exercise in the sunshine — all are important; 
but these are as nothing if the nutrition does not receive 
proper attention. A knowledge of dietetics is far more 
essential to success than a knowledge of drugs in the treat- 
ment of either acute or chronic disease. A careful study 
of the physiology of digestion and assimilation and of the 
composition and value of the different foods clearly shows 
us the means by which we are to construct a diet of the 
greatest utility to our patients. It would seem as if here- 
tofore there had been a great lack of definite knowledge as 
to the construction of diet lists. The usual fault is that 
there is too great a variety for each meal, and much of it 
is comparative!} 7 difficult of digestion. The best argu- 
ment in favor of the more enlightened dietetic treatment 
of a disease is to be found in the clinical results. We 
now know, through a study of physiological chemistry, 
what foods are of high and what of low nutritive value; 
what ones are easily digested and assimilated ; what re- 
quire special gland elaboration before their nutritive ele- 
ments can be utilized; what foods readily ferment, and 
what are the causes of this abnormal change. 

Of especial value are the proteid or tissue-building foods, 



THERAPEUTICS. 273 

and the one which stands at the head of the list, because 
of its utility in these cases, is beef. It is difficult to show 
the importance of the selection of a correct amount of the 
different classes of food. If a certain class is taken in 
excess there is imperfect assimilation, and disease slowly 
but surely results. I have known fatal diabetes to result 
from excessive indulgence in raisins. Oatmeal mush, fer- 
menting in the intestines, is a common factor in the pro- 
duction of nephritis. A vegetable diet contains an injuri- 
ous amount of the carbohydrates and too little of the 
proteid element, which in this combination is difficult of 
digestion. That a meat diet, with a moderate proportion of 
carbohydrates, is the best food for neurotics lias been fre- 
quently demonstrated clinically. Milk has not so great a 
food value as meat because of its greater difficulty of diges- 
tion, its proneness to ferment because of the sugar it con- 
tains, its lack of reparative material — not four per cent, of 
proteids — and the great danger of its being impure. Milk 
may fatten and keep the patient plump, but fat persons 
sometimes have tuberculosis and are frequently neurotic, 
and much of the fat we see is unhealthful. It is, neverthe- 
less, of great value as a nutrient. 

Bearing in mind the best proportions of the three classes 
of proximate principles — viz., that the amount of proteids 
taken should exceed the amount of starchy food and fat — ■ 
it is proper to consider how these proportions can be ob- 
tained in a most nutritive and assimilable form, so that 
while the nutrition is brought to the highest point, elimi- 
nation may not be hindered. In the beginning of the 
treatment the patient should eat nothing sweet, sour, or 
fried, and starchy and farinaceous foods should be entirely 
prohibited, with the exception of a small quantity of stale 

bread or boiled rice, until the digestive and lymph chan- 

18 



274 FUNCTIONAL NERVOUS DISORDERS. 

nels are entirely free from the irritating products of fer- 
mentation. In functional nervous disorders there is 
usually a feeble digestion and frequently a low-grade 
catarrhal and inflammatory state of the digestive tract. 
The internal administration of hot water will tend fo re- 
move this condition and restore the parts to their normal 
state. It is not so much that large quantities of food 
should be taken, but that it should be thoroughly assimi- 
lated. The meat should be lean, juicy beef from the cen- 
tre of the round ; and, after all the fat and fibre have been 
removed, it should be cut into small pieces and passed 
twice through a perfectly clean meat chopper; or it may 
be scraped from the fibrous tissue with a knife or meat 
scraper, or chopped on the block by the butcher. This 
minute subdivision by grinding or chopping makes it most 
digestible. The majority of patients have bad teeth, which 
frequently infect the food. If the meat is not thoroughly 
masticated, the stomach certainly cannot prepare it for 
absorption. It should be kept sterile by handling it with 
perfectly clean hands and by cleansing with boiling water 
every implement it touches. The pulp should now be 
pressed very gently into cakes from one-half to three- 
fourths of an inch in thickness. If they are made too 
thick, they will be difficult to cook, and they should not 
be pressed too firmly together, as this renders them less 
digestible and less palatable. The cakes should then be 
carefully broiled over a clear coal fire, or over one free 
from smoke and blaze, and they should be turned fre- 
quently to retain the juice. If desirable, they can be sea- 
soned with a little salt, pepper, or butter. 

Another method of cooking the beef pulp is to gently 
simmer it with a small quantity of water upon the back of 
the stove for about twentv minutes; it should not be 



THERAPEUTICS. 275 

allowed to boil, as this coagulates the albumin, turning it 
to a gray color, and makes it difficult of digestion. This 
dish is commonly known as Scotch collops. With this 
meat diet a small quantity of dry, stale bread, two days 
old, should be taken. It should not exceed in bulk the 
amount of meat taken. Beef tea of the right kind, prop- 
erly made, or liquid peptonoids, may be given for a short 
time. 

After a time some vegetables can be carefully added in 
small quantity, a mealy potato, or, as before mentioned, a 
little boiled rice, hominy or farina, sago or tapioca gruel; 
but our main dependence must be upon the beef. When 
there is a strong craving for more variety, the dietary may 
be extended by cautiously adding a soft-boiled egg, a 
nicely broiled tender steak, lamb, mutton, turkey, game 
or chicken, French peas or string beans. The succulent 
vegetables, celery, lettuce, dandelion, cauliflower, and spin- 
ach, are sometimes useful, as they assist in overcoming 
the constipation that is frequently present. 

Idiosyncrasy must be considered. 

There are whole families who cannot taste milk in any 
form. I have a patient, a young man of twenty, who can 
never taste tomatoes — even the odor of sliced tomatoes 
being sufficient to make him sick. There are other things 
also, such as asparagus and cauliflower, which it is im- 
possible for him to eat, and like many others, he cannot 
eat Lima beans or yellow beans. Articles having a de- 
cided odor are exceedingly distasteful to him. He has 
never eaten butter and cannot take it in any form, either 
fresh or salt, without it causing excessive nausea. These 
neuroses, as they may be termed, of the gustatory nerve 
are often really psychoses and are exceedingly common. 
Manv of our ordinarv articles of diet are taken as the re- 



276 FUNCTIONAL NERVOUS DISORDERS. 

suit of an acquired taste. This is particularly the case 
with tomatoes, Lima beans, oyster plant, parsnips, carrots, 
and turnips. Many persons cannot eat batter on bread, 
even when extremely hungry, without being nauseated. 
Again, some individuals never eat salt, while others take 
inordinate quantities. In these cases there is always 
digestive derangement and generally decomposition of 
starchy, saccharine, and fatty articles of diet. In the 
foregoing regimen these have been excluded to a great 
extent. If constipation be present, a little Turkish rhu- 
barb, or, better still, a small glass of senna tea, with an 
aromatic such as fennel to obviate griping, or a teaspoon - 
ful of table salt in a glass or two of cold water, may be 
taken on going to bed or on rising. Bad cooking and in- 
digestible food, like cheese, pastry, baked beans, corn, 
lobsters, clams, pork, greasy macaroni, sausage, cabbage, 
pickles, porridge or mush, hard-boiled eggs, salads, veal, 
doughnuts, nuts, raisins, raw onions, cucumbers, fruits, 
and impure milk should be carefully avoided. To this 
may be added strong tea and coffee, especially the latter. 

As regards liquids, the patient may be allowed to drink 
a cup of properly prepared, thick, home-made beef tea, or 
the expressed juice of beef every two or three hours, if 
very weak; otherwise only at meals. Peptonized milk, or 
milk and Highland water, or cocoa, or very weak tea, 
may also be taken for a change, but without sugar. 

The patient should have a table to himself or eat alone ; 
otherwise there will be a temptation to indulge in articles 
not permitted. When the appetite increases very much, 
four meals may be taken daily, if needed, but at regular 
hours, the last one not to be later than seven o'clock. It 
is not well for the physician to be too strict in regard to 
diet, nor prejudiced against certain foods, as individuals 



THERAPEUTICS. 277 

vary. The meals should be simple, and confined to a few 
articles, the fewer the better. 

Elimination of the diseased products is of extreme im- 
portance in all acute and chronic diseases. When the 
vitiated matter is removed by elimination the disease can- 
not be so severe, as then there is an internal asepsis which 
prevents bacillary development. The eliminating organs 
should be stimulated, and hot water is the blandest and 
most efficacious means of accomplishing it through the 
kidneys. A glass or two of hot water should be taken an 
hour or two before meals, and half an hour before retiring, 
and enough fluid, preferably water, with the meals to 
assist digestion and absorption. It would be well if hot- 
water shops were as common in this country as in China ; 
they would to a degree be a substitute for the liquor stores, 
and would accomplish the same purpose in removing in- 
ternal cravings and stimulating the patron without intox- 
icating him. 

After elimination the next important step is to build up, 
when possible, the diseased and broken-down tissues. 
This is accomplished by stimulating the manufacture of 
pure, fresh blood. 

In neurotics, there being an excess of waste, we must be 
careful to get the proper quantities and proportions of pro- 
teid and carbohydrate foods, and have the waste products 
completely oxidized. When fresh meat is taken there is 
an increase in the red corpuscles — the oxygen carriers — 
but there is a limit to the quantity of food that can be oxi- 
dized. Ordinarily, we take too much carbohydrate food, 
and our meats (proteids) are, except in the largest cities 
and among the more intelligent, usually improperly cooked 
— most generally fried. It is the taking of excessive 
quantities of indigestible and stimulating foods that causes 



278 FUNCTIONAL NERVOUS DISORDERS. 

disease. To maintain the highest standard of health, 
more of meat than of vegetable food should be taken. 
Carnivorous or meat-eating animals seldom have con- 
sumption, while it is quite common in the herbivorous or 
vegetable-eating animals. The greater " vitality" or activ- 
ity of the former as compared with the latter is worthy of 
note. 

The fallacies of a purely vegetable diet are most com- 
monly demonstrated by the bedside of the patient. Such 
a diet requires a greater amount of oxygen and more ex- 
tensive elaboration by the glandular structures of the body, 
and results in an excess of waste, which must be excreted. 
I have seen nephritis developed by the excessive indulgence 
in cereal and fried foods. Milk, although almost univer- 
sally recommended, is not a good exclusive diet for a con- 
sumptive. It is all right for small children and babies, 
who simply require to be kept warm with fattening food. 
Experience has taught me that a meat diet is far prefer- 
able for adults. It is a concentrated and most nutritious 
food, and withal is easy of digestion. In Japan there are 
scarcely any cows, yet the people are in good health. 

In treating neurotics we should give attention to both 
the liver and the lungs. We should restore the biliary 
secretion to a healthy standard, both as to quality and 
quantity. From our standpoint the liver is the most im- 
portant organ, for by its defective elaboration of food pro- 
ducts nutrition is impaired, and anaemia and disease result. 
Overfeeding and improper feeding tend to imperfect elabo- 
ration and elimination by giving the liver and kidneys too 
much work to perform. 

I do not discard milk in cases of neurasthenia and other 
functional diseases, but I think too much reliance has been 
placed upon it alone as a reconstructive tissue food. There 



THERAPEUTICS. 279 

are many who say they cannot take milk, but the stomach 
can be trained to receive it and in a short time to relish it. 
A very small quantity should be given at first. It should 
be remembered, however, that milk has been shown to 
contain a number of parasites and bacteria. 

In these diseases the increased digestion of nitrogenous 
food is our sheet anchor, and when this is inadequate 
there is no arresting the progress of these maladies. Even 
in cases in which the lungs are involved the progress of the 
disease can be permanently arrested, if too much tissue 
has not been destroyed. While nothing gives such good 
results as dietetic treatment, aided by medicines, a careful 
preparation of the digestive tract and its appendages 
should not be omitted. This not only removes catarrhal 
and inflammatory states, but gives tone and strength to 
the muscular and nervous systems, stops diarrhoea, nausea, 
and fever, restores the appetite, and increases and enriches 
the blood supply. Such treatment, when combined with 
proper climate and other hygienic and medicinal remedial 
measures, brings back health and vigor to many an appar- 
ently hopeless neurasthenic. 

The following rules should not be regarded as infallible 
and absolute guides, but serve as important hints, the 
application of which the attending physician will point 
out: 

(1) Be careful to eat enough, but not too much. It is 
said that the majority of persons eat too much. I am sure 
there are a vast number who eat too little. Use great care 
as to the quality and kind of food taken. 

(2) Do not eat too rapidly or drink too much liquid 
during the meal, as this tends to imperfect mastication 
and to bolting the food. 

(3) Do not take a great variety at each meal, but con- 



280 FUNCTIONAL NERVOUS DISORDERS. 

tent yourself with a few articles of the simplest and most 
nutritious kind, such as stale white bread, boiled rice, 
hominy, or farina; fresh beef, mutton, or lamb; fresh fish, 
oysters, mealy baked or boiled potatoes, celery, cauli- 
flower, spinach, lettuce, tomatoes. 

(4) Do not use strong tea, coffee, or stimulants unless 
specially permitted. Eat nothing sweet, sour, or fried. 
Meats should be fresh and of the best qualit}\ They are 
best broiled rare, and should be eaten hot. Beef and mut- 
ton, if not broiled or roasted, should be stewed until very 
tender. Eggs should be poached or soft boiled. Corn 
bread, as a rule, is made too sweet, otherwise it is very 
wholesome. No saleratus biscuits, hot or cold, or pancakes, 
except on rare occasions, should be taken. Rice, hominy, 
farina, cracked wheat, and cornmeal can be used. 

Occasionally, after the patient becomes somewhat 
stronger, strained oatmeal gruel can be taken. It is best 
cooked in a water bath; that is, a vessel for the purpose 
set in a pot of boiling water. This prevents it from burn- 
ing. It should cook for several hours. It can be used 
with milk or cream. 

For drinking purposes nothing equals good, pure soft 
water, from a granite or trap-rock region. If the stomach 
is tender, it is an excellent plan to sip slowly a glass of hot 
water half an hour before meals or during the meal, with 
a little milk added to give it color. Cacao is digestible 
and strengthening. Skim milk is also useful, and is best 
taken hot. 

As it is difficult for the patient to remember lengthy 
verbal statements, especially when also the exact dosage 
and manner of taking the drugs prescribed must not be 
forgotten and is always considered by them of the greatest 
importance, any of the following articles of diet or the 



THERAPEUTICS. 



281 



rules which are necessary in the treatment of the case can 
be underlined or pen-marked at the side of a prepared list : 



MEATS. 



Beef. 

Mutton. 

Lamb. 

Chicken. 

Turkey. 

Duck. 

Game. 

Beef tea (thick) . 

Mutton broth (thick) . 

Chicken broth (thick). 

Liver. 



Eggs (poached or soft-boiled). 

Oysters. 

Fresh fish. 

Butter. 

Buttermilk. 

Thick milk. 

Sweet milk. 

Kumyss. 

Soups. 

Milk puddings. 

Custard. 



White wheat bread (stale) . 

Brownbread. 

Roasted bread. 

Toast. 

Corn bread. 

Crackers. 

Rice. 

Hominy. 

VEGETABLES, 

Potatoes (white). 

Potatoes (sweet). 

Peas (tender). 

Beans (white). 

Beans (Lima). 

Spinach. 

Celery. 

Cauliflower (boiled). 

Cabbage tops (tender) . 

Lettuce. 



Farina. 

Cracked wheat. 

Cornmeal mush. 

Macaroni. 

Cornstarch pudding. 

Germea. 

Arrowroot. 

FRUIT. 

Tomatoes. 

Onions. 

Bananas. 

Melons. 

Peaches. 

Grapes. 

Prunes. 

Apples (baked or stewed) , 

Oranges. 



DRINKS, 



Cacao. 
Chocolate. 
Caramel coffee. 
Lemonade. 



Whey. 

Chicken broth. 
Beef tea. 
Mineral waters. 



The food question recurs three times every day and is 
an important one. There are many nervous patients who 



282 FUNCTIONAL NERVOUS DISORDERS. 

do not take enough food, fearing that it will not be digested 
and cause distress from pain and flatulence. Some of 
these patients have a great many dislikes, which thus cur- 
tail the variety of food greatly, so much so that it is com- 
mon to find them in a state of partial inanition. Often- 
times they are quite hysterical on this point. Much of 
the food they prefer is indigestible or made so by improper 
cooking. Gradually the dietary of these patients should 
be enlarged, especially the fresh meat portion of it, until 
sufficient is taken to supply the actual needs of the body. 
As a rule, stimulants of all kinds should be forbidden. In 
certain cases it is desirable that four or even five meals 
should be taken daily, but these should not be large, as 
the patient might thus overeat. The following is a sam- 
ple of what might be taken : 

Breakfast^ 8 to 9. Hominy, rice, farina, or arrowroot, 
with rich milk or cream; two or three small chops, with a 
slice or two of bread and butter; a glass of water, hot or 
cold, after the meal. 

About eleven or twelve o'clock a cup of beef tea or a 
glass of milk and a cracker can be taken, if the patient is 
hungry. 

Luncheon, 1 to 2. Fresh meat or fish, either roast, 
broiled, or boiled. Beef, mutton, or lamb; mashed or 
well-baked potatoes; some green vegetables, such as let- 
tuce, celery, cauliflower, or tomatoes ; finally a plain milk 
pudding, with a cup of weak tea, cacao, or milk. 

Supper. Fresh fish, soft-boiled eggs, chicken, or turkey, 
bread and butter; a glass of cold or hot water containing 
a little milk. 

On retiring a cup of beef tea, cacao, or chocolate, agree- 
ably prepared, may be taken if desired. If wines are 
desired, a small glass of claret or Burgundy may be taken 



THERAPEUTICS. 283 

at luncheon. As a rule, patients do better without alco- 
holic stimulants. 

When there is a condition of great nerve exhaustion, 
placing the patient away from friends and relatives in a 
properly conducted sanatorium is of marked benefit. 

On entering, a very careful physical examination 
should be made and recorded. This should include the 
patient's weight and dynamometer strength of the impor- 
tant muscles. 

The Weir Mitchell plan of treatment is often of great 
benefit to these patients. About four ounces of milk 
should be given every two hours while the patient is 
awake, but they should not be awakened to take it, the 
quantity should be gradually increased until at least two 
quarts are taken daily. If it disagrees and makes the pa- 
tient "bilious," a little salt or some lime water should be 
added to it, after diluting it with boiling water. After a 
few days plain nutritious foods can gradually be added, 
until a full diet supplements the milk taken. After a time 
the superalimentation can be gradually reduced and open- 
air physical curative exercise indulged in to a great ex- 
tent. 

All dietetic, general, tonic, or other treatment is useless 
unless there is a plentiful supply of pure air. Pure air is 
a great stimulant to the appetite and digestion by reason 
of the oxygen which it" contains. The rooms occupied by 
the sick person should therefore be carefully ventilated, 
without producing draughts, and in cold weather should be 
filled with a genial warmth. The patient should be out of 
doors as much as possible when the weather is not too 
severe. Oxygen should be forced, so to speak, into the 
lungs by an atomizer attached to an air compressor. It is 
the sine qua non in all nervous and lung diseases. It can 



284 FUNCTIONAL NERVOUS DISORDERS. 

also be used in the form of pyrozone, or peroxide of hydro- 
gen, properly diluted for inhalation or the spray. 

Gentle and systematized exercise, without fatigue, has a 
very beneficial effect upon nutrition by stimulating the 
action of the heart, accelerating the circulation, and in- 
creasing the respiration. It thus increases the oxidation 
of waste products and leaves room for the assimilation of 
nutriment. For the weak, a daily carriage ride is bene- 
ficial, and for those who cannot afford this the street 
cars can be utilized. Boat rides on bays, lakes, or rivers, 
and sea voyages are also often very beneficial; but the 
invalid must be well wrapped up. For those who are 
able, walking in moderation is a very useful form of 
exercise. 

Voluntary exercise is best given in the form of scientific 
gymnastics under a competent medical instructor, and it 
should be carried to the point of moderate fatigue of the 
muscles used, but no farther. 

The arms and chest muscles are especially to be exer- 
cised, and this is accomplished by light dumbbells. 

If the patient is extremely weak, passive exercise by 
Swedish movements or massage may be given. For con- 
stipation and indigestion local abdominal massage should 
be employed. 

In certain institutions, sanatoriums, and schools of phys- 
ical culture passive exercise is given in a perfected man- 
ner. Properly performed, it is of great value to nervous 
invalids. The rubbing, pressing, and shampooing which 
the muscles get strengthens them without calling for any 
nerve expenditure. The skin is nourished, hardened, and 
strengthened by the same process. Under it, combined 
with the muscular exercise and the shower, the obese lose 
fat and the lean grow plump from a new development of 



THERAPEUTICS. 285 

healthy muscular tissue. It would seem to be as neces- 
sary to groom the human animal as it is the horse. The 
result is about the same; both thrive under it. Not every 
nurse or operator can give passive exercise in a proper 
manner. It requires a special knowledge and training. 
As a remedial measure it is adapted to many disorders of 
the nervous system. The best time for its application is 
immediately after the showerbath, aud it may be given 
in some cases twice a day. After the body has been well 
dried the frictions with the hand or bath glove should be 
systematically given to all parts of the body. The muscles 
and parts that are weak and require it should be especially 
worked under the fingers, and all dampness and coldness 
removed by the stimulating healthy effect of the frictions 
upon the circulation. Many other motions are used, such 
as kneading and tapotement or percussions, and the nutri- 
tion of the body is much improved as a consequence. A 
good time for the exercise is early in the morning before 
breakfast, or three or four hours after a meal. After the 
exercise the patient should rest for at least an hour if 
possible. 

The curative exercise and massage ought to take from 
thirty to ninety minutes, according to the condition of the 
patient. 

The skin should assist in the work of elimination and 
protection. Cool or cold sponge baths, according to the 
vitality of the patient, have a most salutary effect. A fine 
shower is preferable to the sponge or dip. Its duration 
should be exceedingly brief, and after it the skin should be 
rubbed dry with coarse towels. Assisted by the patient 
herself, the bath should be taken in a room of mild tem- 
perature. Followed by massage, the cool bath is one of 
the greatest nerve and brain tonics known. A hot sponge 



286 FUNCTIONAL NERVOUS DISORDERS. 

bath, with a little kretol added, should be taken at night, 
and the body should be vigorously rubbed afterward. If 
there is a tendency to "catching cold," the body may be 
well rubbed with some nutritive oil. 

In order to sleep, the mind should be kept from exciting 
occupation, especially toward evening. The room should 
be well ventilated and the bed comfortable. The evening 
meal should be light and simple, and no food should be 
taken as a rule immediately before retiring. Care should 
also be taken to avoid stimulants. An abundance of un- 
disturbed sleep is of vital importance to nervous invalids. 
They should retire promptly at ten o'clock, if not before. 
The importance of improving the nutrition of the neurotic 
is acknowledged by all physicians. By careful attention 
to the foregoing method the quality of the blood and the 
general nutrition of the body are greatly improved. Mal- 
nutrition in all degrees is found among the nervous, and 
especially those suffering from neuralgia. The rational 
treatment for such cases is to fill the blood-vessels with 
blood rich in nutritive materials to feed the impoverished 
nerves, as starvation is at the foundation of most of the 
nervous ills. Most of the cases result from anxiety, im- 
proper diet, and deficient sleep. It is not so much work 
as worry that does the damage. Forced feeding, as a 
sequence to muscular exercise in a pure atmosphere, and 
mental as well as physical rest are what is needed. When 
this is properly carried out the patients, as a rule, rapidly 
recover. It is a simple means of treatment, yet a success- 
ful one. In severe cases isolation, change of scene, and 
electro-therapy may be required. Outdoor exercise is very 
beneficial to all nervous invalids. 

Flannel garments, of a thickness suitable to the season, 
should be worn. It would be difficult to get them too 



THERAPEUTICS. "28? 

thick for our severe winters. In cold weather the stock- 
ings should be of wool. 

Corpulence. — Neurasthenic patients who suffer from 
corpulence may experience much benefit by excluding for 
a short time from their diet all fatty foods, or those that 
are converted into fat, such as sugar aud farinaceous 
foods, bread, potatoes, beets, parsnips, carrots, turnips, 
rice, hominy, beans, peas, and substituting spinach, cel- 
ery, tomatoes, lettuce, cauliflower, greens, cabbage free 
from stems, buttermilk, skimmed milk, oysters, eggs and 
meat, except pork or veal. All vegetables grown under- 
ground should be avoided. 

A lean-meat diet is essential in this affection, but it 
must be properly prepared, otherwise the patient will soon 
get disgusted and abandon it. Properly prepared, and jn 
proper quantities, it can readily be taken for a long period 
with a relish. 

The modes of preparing and cooking meat which have 
already been given may be used in the case of corpulency, 
and the following additional recipes will be found advan- 
tageous. 

Methods of Cooking the Ground Meat. — Scotch col- 
lops: Put one pound of chopped or ground beef in a 
stew-pan and add enough cold water to cover the meat; 
add an onion cut up fine and a little salt and black pepper. 
Simmer carefully on the back of the range (it must not be 
allowed to boil) ; add a little sauce free from red pepper 
shortly before serving, and garnish with small, thin pieces 
of roasted bread, not too crisp or hard. 

The following is another way of cooking the chopped 
meat, is very pleasant for a change, and when so pre- 
pared it is easily digested : 

Take one pound and a half of chopped or ground beef, 



288 FUNCTIONAL NERVOUS DISORDERS. 

one pint of good meat soup, free from fat ; simmer care- 
fully over a gentle fire until well cooked. It must not 
boil, as this coagulates the albumin, interfering with its 
digestibility and its value as nourishment. This is more 
palatable than the beef cakes, even when they are soaked 
in meat soup before broiling. 

A nice dish for a change is to take some stock and a 
little boiled milk, and add one-third the quantity of bread 
crumbs to the chopped beef, mixing well together and mak- 
ing into soft cakes about three-quarters of an inch thick. 
Brush over them, beaten white of egg and broil carefully 
over a clear coal fire. 

Still another way is to broil the meat slightly, pass it 
through the meat chopper, and then mix it with good 
meat soup free from grease and simmer carefully until 
cooked over a gentle fire, being careful not to let it boil. 
This is very nourishing. 

Frequent bathing, especially Turkish baths, accompa- 
nied by vigorous massage, walking, exercise, or bicycle 
riding, must be taken. Cold water and kretol baths of 
short duration have a delightfully stimulating effect upon 
the skin. Large quantities of fresh air should be inhaled 
to oxidize the excess of fat, which the hot water then 
eliminates. 

With the above is combined the medical treatment, con- 
sisting of the chlorate and iodide of potassium as oxidi- 
zers, and such other remedies as are indicated and usually 
prescribed. 

The physician should make such modifications in the 
diet as the condition of the patient requires. 

Much of the food eaten not being digested, it undergoes 
fermentation, evolving yeast, carbonic acid gas, vinegar, 
or alcohol. Instead of nourishing the body, a catarrhal 



THEKAPEUTICS. 289 

state of the digestive organs is the result of this fermenta- 
tion, and a diseased condition of the tissues of the body 
supervenes. 

In perfect health the normal amount of adipose tissue 
should not exceed five per cent of the total weight of the 
body. Obesity is due usually to defective oxidation of the 
excess of food taken, and of the waste of the body gener- 
ally. It is a disease process resulting from eating to ex- 
cess of all kinds of food, and especially those that form 
fat. Excessive use of alcoholic beverages and lack of ex- 
ercise in the open air are also great factors in its produc- 
tion. It is simply the outcome of wrong physical habits, 
and especially improper alimentation. The difficulty of 
breathing, the great enlargement of the body, and interfer- 
ence with easy movements are the principal symptoms 
which attract the attention in this condition. 

The cure of this disease is safe and rather simple by a 
rigid adherence to a proper dietary. In a comparatively 
short time, as a result of the treatment, the digestive or- 
gans are restored to a healthy state. In a very extensive 
experience during the last ten years with this plan of 
treatment, I have seen that, when honestly carried out as 
advised, it has usually been successful, and has never been 
productive of anything but good to the patient, as it is 
based upon scientific principles. 

Special feeding is here indicated by the condition of 
the system, and acts as a means of cure in this disease, 
which has, as a rule, resulted from unhealthy feeding. 

The hot water should be carefully taken as advised, as 

it is a most important part of this method of treatment. 

The action of hot water in the stomach and intestines has 

already been fully discussed. It should be quite hot, but 

still of a comfortable temperature — anywhere between 110° 
19 



290 FUNCTIONAL NERVOUS DISORDERS. 

* 

and 130° F. — and not simply warm, as warm water nau- 
seates. It may be slightly disagreeable to take at first, 
but one soon gets accustomed to it. A pinch of salt or a 
few drops of lemon juice may be added if desired. Many 
physicians advise almost complete abstention from liquids, 
but it seems to me that this is a dangerous procedure and 
liable, from the non -elimination of the poisonous waste of 
the body, to cause arterial and renal disease. 

When digestion and assimilation are much interfered 
with, as in this disease, the diet of ground or chopped 
beef is indicated, it being very easy of digestion and as- 
similation. It is rapidly absorbed and enriches the blood, 
which is always in this disease deficient in the oxygen 
carriers (the red blood corpuscles). Carefully broiled, ten- 
der steak is nearly as useful as the ground beef, but it 
should be well masticated. Although it is not a fattening 
diet, it is very strengthening, making the weak happier 
and more comfortable as a result of their renewed health. 

This is a hard diet, and a great deal of self-denial and 
perseverance will be necessary. It is best to eat alone and 
yet be in the room with company. Thus the temptation 
to indulge in forbidden articles of food is avoided. If 
there is a feeling of weakness or insomnia at night, drink 
a little beef tea, or have a sandwich or cracker at hand. 
In beginning the treatment the patient ma3 T feel a trifle 
weaker in body for a day or two, owing to the absence of 
the products of fermentation, alcohol, etc., but this is nat- 
ural and to be expected. The patient should at first keep 
quiet, and he will rapidly grow strong and his mind will 
feel stronger and clearer. There will immediately begin a 
shrinkage in weight as the diseased fat disappears. Out- 
of-door exercise should be taken — walking, bathing, dumb- 
bell exercise for ten minutes, three times daily, three hours 



THERAPEUTICS. 291 

after meals. As a rule all stimulants are forbidden, ex- 
cept as specially ordered by the physician. 

Obesity is simply a disease, and must be treated as 
such. The fat accumulates because it is not oxidized. 
Alcohol, taken as a beverage and generated in the intes- 
tine by fermentation of starchy food, interferes to a marked 
extent with oxidization. 

The following bill of fare will be found to be an excel- 
lent one in these cases : 

Breakfast. Four to five ounces of chopped beef, 
chicken, mutton, or game, or broiled white fish. One 
large cup of weak tea, without milk or sugar. 

Dinner. Five or six ounces of any white fish except 
herring or eels ; any kind of poultry or game; any meat 
except pork or veal; a biscuit or a slice of stale bread; 
a tablespoonful of liquid peptonoids in water. 

Supper. Three or four ounces of chopped beef, chicken, 
and two small slices of stale bread. 

A pint of hot spring water should be sipped at intervals 
every two hours. As a laxative, when needed, a wine- 
glassful of senna tea, with a little fennel added, may be 
taken. 

Assimilation. — By the term assimilation is meant the 
phenomena of the incorporation of food taken by living 
beings into their own tissues. This, in other words, is a 
storing up of products to be used in the development of 
energy, with the resultant formation of waste products. 
The latter are thrown off by the excretory organs, i.e., 
the bowels, kidneys, lungs, and skin. 

Of the substances used as food, water is the most im- 
portant. The processes of digestion, absorption, and tissue 
metabolism cannot go on without it. One can survive 
upon it longer than upon any other single alimentary prin- 



292 FUNCTIONAL NERVOUS DISORDERS. 

ciple; it is not only food, but a digestive agent as well> 
and constitutes from fifty-eight to seventy per cent, (ac- 
cording to different authorities) of the body weight. The 
various substances destined for excretion require water for 
their solution, especially so in the urine. The water for 
drinking is usually obtained from springs, although river 
waters, which are less pure, are frequently used for this 
purpose. Granite-rock water (of which the Highland 
water is a good example) constitute the best class of po- 
table waters; next come the trap-rock waters. The spar- 
kling lime-rock waters, like Apollinaris, are also palatable 
and pleasant to use, but not quite so digestible as the 
former. A good drinking-water should not be too hard ; 
it should be colorless and without odor. When there is 
the slightest suspicion in regard to its purity, it should be 
thoroughly tested to see that it is free from organic matter 
in a state of decomposition, as many of our most fatal dis- 
eases, such as typhoid fever, cholera, and dysentery come 
to us through the water supply. Milk, or some of its 
preparations, while a complete food for infants, is not suit- 
able alone for adult life, as it contains relatively more 
fat and sugar than necessary proteids. Boiling tke milk 
coagulates the albumin, making it insoluble and difficult of 
digestion. Cow's milk is richer in proteids and poorer in 
sugar than human milk ; its curd is more dense and much 
more difficult of digestion. It is much influenced by the 
food given to the cattle; carrots, turnips and parsnips 
changing not only the odor, but the color and flavor also. 
Fragrant grasses modify the taste of milk and butter. 
This is seen in the superiority of June butter. Milk is 
frequently the means of communicating infectious dis- 
eases, such as scarlet fever and measles. Steaming the 
milk by raising the temperature to scalding, but not to 



THERAPEUTICS. 293 

"the boiling-point, is useful in destroying impurities which 
may be present, and thus sterilizing it. 

Beef and other proteid foods increase the amount and 
richness of human milk ; the fats present in the milk are 
not obtained from fats ingested, but from a splitting up of 
the proteid molecules. A pure, fresh meat diet gives milk 
containing a large amount of fat ; the milk sugar and ca- 
sein are also derived in the same way from the proteid food 
taken. 

Animal Food. — Besides the muscle substance, all beef 
contains more or less fat ; the red color is due to the haemo- 
globin present in the meat substance; the salts are potash 
and phosphoric-acid compounds. Magnesium phosphate 
and calcium phosphate are also present in smaller amount. 
The amount of fat present varies according to the con- 
dition of the animal, and is given differently by different 
authorities. In the substance of the meat itself, after the re- 
moval of visible fat, there is said to be about eleven per cent, 
in the ox, and three per cent, in the sheep and in the fowl, 
about two per cent, of fat still remaining. Beef contains 
four times the amount of proteids as milk. In Great Britain 
and America beef leads all other meats as a staple. Roast 
beef is the form it takes in England, while in the United 
States fried steak is the most common form in which we 
find it. The latter, I need scarcely say, is extremely 
indigestible. Contrary to the general opinion, rare beef is 
not nearly so beneficial as that which has been properly 
cooked. Cooking is really a partial digestion, as it softens 
the fibre and makes it easy of maceration in the stomach. 
Warm foods of all kinds are more digestible than cold 
ones, and this is a fact to be remembered when the diges- 
tion is weak. Steaks should be broiled by a quick yet 
gentle heat ; all beef should be thoroughly masticated, and 



294 FUNCTIONAL NERVOUS DISORDERS. 

not eaten in too large amount at any one time. Improper 
mastication may result from defective teeth, but more 
often the pernicious habit of bolting food is the cause of 
the weakened digestion. An occasional glance at some 
work upon table etiquette may assist in overcoming this 
habit. Roast beef is very wholesome; the outer or first 
cut is less digestible than the inner slices. Mutton is 
digestible, but not so nourishing as beef, and is very whole- 
some when roasted. Boiled, with caper sauce, and served 
with fresh, well-cooked vegetables, it is digested by very 
weak stomachs, and is nourishing. 

The preparation of meat is the essential thing to be con- 
sidered; in roasting it must not be burned, and in boiling 
it should not be cooked to pieces. All boiled meats should 
be allowed to stand in their own liquor for some time after 
the boiling has ceased, to reabsorb the juices; otherwise 
they will be dry. Veal is not often digestible, although 
often tender. It must be carefully cooked. Pork should 
be selected with great care ; it must not be dark nor very 
red, but of a delicate pink color, with very white fat. 
Salted meats should be only mildly salted and not old, as 
the process of salting toughens them. Simmer the meat 
gently, as furious boiling is not of advantage. In spite of 
the reputation which bread has obtained as the staff of 
life, meat is certainly more nutritious and strengthening. 

Vegetable Foods. — The cereals are the most important 
of the vegetable foods ; they contain not only starch, pro- 
teids, and salts, but about fifteen to twenty per cent, of 
water. The nitrogenous element is most abundant on the 
exterior of the grain, but coarse foods, containing much 
bran, are indigestible. The finely ground flours or meals 
are the preparations most suitable to digestion ; some of 
the cellulose or external envelope, however, may be di- 



THERAPEUTICS. 295 

gested. The more fat a vegetable food contains, the more 
difficult is it of digestion. Vegetable proteids are useful, 
but they are not so easily digested and elaborated as the 
animal proteids. There is also more waste from vegetable 
than from animal food. The farinaceous substances are 
largely composed of starch, while the leguminous seeds, 
such as peas, beans, and lentils, contain much proteid 
matter, and are largely used in the form of soup by the 
poorer classes. 

Potatoes contain principally water and starch, about 
two per cent of soluble albumin, a small amount of pot- 
ash and of chloride of sodium. There are also present in 
the cellular tissue phosphoric, malic, and hydrochloric 
acids. Green vegetables and fruits are chiefly of value 
for the salts they contain; they are therefore of use in 
scurvy and allied conditions. They fill an important 
place in the treatment of functional diseases in women. 

Food Accessories. — Alcohol, taken regularly in large 
doses, has a profound effect upon the nervous system, 
affecting all the mental and bodily faculties; by its direct 
action upon the digestive organs it causes catarrh and 
inflammation. Up to a certain extent, the alcohol taken 
into the system is readily oxidized. It often acts as a 
substitute for food which may be insufficient in amount, 
but it interferes markedly with oxidization. Small doses 
excite and large doses paralyze the nervous system. Its 
stimulating action is always followed by a corresponding 
depression. In small doses it gives a feeling of warmth, 
but even moderate doses lower the temperature of the 
body. Brandy more than whiskey hampers salivary diges- 
tion, although some claim that it promotes it by causing 
an increased flow of saliva. All wines have a strong re- 
tarding effect upon salivary digestion ; claret, sherry, port, 



296 FUNCTIONAL NERVOUS DISORDERS. 

and hock even in so small a proportion as one per cent 
have a marked inhibitory effect. This is probably due to 
the acidity of these wines. Digestion is interfered with 
by malt liquors, according to their acidity. We have 
spoken before of water, and would merely observe in this 
place that although, as above demonstrated, wines have 
an inhibitory effect upon salivary digestion, this can be 
materially lessened by the addition of water containing 
the alkaline carbonates. 

Alcoholic beverages should be given with the greatest 
reserve to neurasthenics or nervous persons. As a rule, it 
is better not to prescribe them at all, unless in combination 
with the bitter tonics. 

Tea exercises a most decidedly inhibitory effect upon 
salivary digestion, undoubtedly on account of the tannin 
contained in it ; when used at all by persons whose diges- 
tive powers are in any way impaired, it should be made 
extremely weak and be partaken of sparingly. About five 
grains of the bicarbonate of soda in the teapot will remove 
the restraining action which it has upon the salivary 
digestion. 

Coffee, in this respect, is far less harmful than tea, and 
the same may be said of cacao. The latter is popularly 
supposed to favor digestion much more than tea or coffee, 
probably because it is used in a much weaker state than 
either of the other beverages; it is commonly used in about 
a two-per-cent infusion, whereas tea and coffee are used in 
about a five and seven per cent infusion respectively. 

Sugar and common salt, although exercising a very 
considerable influence upon peptic digestion, seem neither 
to favor nor to retard the salivary digestion. Salt, being 
to a certain degree a condiment, excites the secretion of 
the saliva. Sugar is very fermentable. 



THERAPEUTICS. 297 

Gastric digestion being of greater extent than salivary, 
it is important to note the effect upon it of many food 
accessories. The effect of ardent spirits, such as brandy, 
whiskey, and gin, depends upon the amount of alcohol they 
contain ; the greater the amount the more do they embarrass 
digestion. In the proportions commonly used at meals 
they have no appreciable action of the kind, neither are 
they in any way beneficial. If they be taken at all, they 
should invariably be diluted and drunk in small amount, 
as large amounts markedly impede digestion. 

Wines and beers have a much more inhibitory influence 
upon gastric digestion. Very small quantities of cham- 
pagne have a slightly accelerating effect, due probably to 
the stimulation of its effervescent qualities, while claret, 
sherry, and port, more especially sherry, have a markedly 
retarding action. The same may be said of malt liquors. 
When taken in large quantities, they very decidedly re- 
tard the digestion of bread and other starchy articles of 
food. Tea, coffee, and cacao in strong infusions have a 
powerful retarding influence on gastric digestion, but when 
taken in weak infusions, as cacao is usually made, the 
effect is slight. The retardation is especially noticed with 
starchy foods. Table or small beer, as used in England, or 
very light lager beer, such as the two-per-cent. beer, taken 
while in its effervescent state, has probably no deferent 
effect on gastric digestion, or none worth mentioning. 

The influence of these food accessories upon pancreatic 
digestion is much less marked than upon the gastric or 
the peptic. 

Medicinal Treatment. 

Reconstructive Remedies. — Many drugs are employed 
with good results in the treatment of nervous disorders. 



298 FUNCTIONAL NERVOUS DISORDERS. 

Coffee, and its alkaloid caffeine, are especially useful as a 
domestic remedy for slight migrainous headaches which 
come on after meals, and is a common and extremely valu- 
able remedy for functional headaches. Cafe noir is sup- 
posed to be efficacious in hastening digestion, but in many 
nervous dyspeptic persons its use is detrimental. In ner- 
vous asthma coffee and caffein are often very useful when 
administered in strong doses. The reflex vomiting of 
pregnancy is often checked by the use of alcoholic drinks, 
as whiskey or brandy, and these stimulants in small doses 
will sometimes be found useful in the class of cases under 
consideration in this work. Generous wines in small 
quantities act as a reparative food, and, as they restrain 
the waste of nervous tissue, they will be found most use- 
ful agents. They are to be used only where unmistak- 
ably indicated, as there is always some danger of inducing 
the alcoholic habit. They by no means take the place of 
the natural food of the body, although their use, it is sup- 
posed, may sometimes tide the patient over a critical 
period. 

Among the best tonics for neurotic individuals are the 
cinchona preparations, more especially in those cases 
which have a malarial element, characterized by a perio- 
dicity or intermittency of the symptoms. As bitter tonics 
and appetizers they are of advantage to stimulate the 
digestive powers, thus assisting nutrition and strengthen- 
ing the entire system. One of the best of these prepara- 
tions is the sulphate of quinine; in small doses it acts as 
a good heart stimulant, and is preferable to digitalis in 
cardiac disorders. In large sedative doses it is dangerous 
in this class of cases. In certain reflex nervous asthmas, 
reflex coughs and dyspnoeas, however, large doses may be 
administered with advantage. The cinchona preparations 



THERAPEUTICS. 299 

(more especially the sulphate of quinine) act most bene- 
ficially and quickly in neuralgias of malarial origin. It 
will be found advantageous to combine the quinine with 
opiates if the pain be very persistent and severe. Mi- 
graine is benefited in most cases by a combination of 
quinine and digitalis. 

In functional and catarrhal affections of the stomach 
and intestines, an infusion of calumba is very useful in 
restoring the digestion to its normal condition. A bitter 
tonic, disagreeable to take, but sometimes of value, is 
quassia; it often very quickly relieves vertigo of stomachic 
origin. Another extremely bitter tonic is gentian; it is 
often valuable in stimulating the digestion in functional 
nervous disorders, and usually succeeds in removing the 
debility which is at the root of these ailments. The com- 
pound tincture of gentian is an excellent product, and can 
be combined with the cinchona preparations, which are 
the best of all this class. These should be taken in small 
quantities and at regular intervals; they all increase the 
force of assimilation and thus act as strong nerve tonics. 

Condurango, which has been in bad odor from its hav- 
ing been recommended as a specific for cancer, is said to 
be a good stomachic and appetizer. I have seen admi- 
rable results from its use, in increasing the appetite and 
the digestive powers, when its fluid extract has been com- 
bined with the tincture of nux vomica. However, Lauder 
Brunton claims that it is physiologically inert {Journal 
of Anatomy and Physiology, April, 1876). 

Arsenic in the form of Fowler's solution is a good tonic 
to the nervous system ; through its beneficial action on the 
digestive function it gives tone and strength to all the 
organs, thus increasing the vital resistance. It should be 
used with great caution, in view of its poisonous properties. 



300 FUNCTIONAL NERVOUS DISORDERS. 

Where there is no inflammation of the digestive organs, 
a good bitter tonic, with the addition of a little capsicum, 
is all that will be required in the way of medicine, but a 
generous supply of nutritious food should be given. When 
severe nasal or gastric catarrh is present, this must be first 
removed before any efforts are made toward the enrich- 
ment of the blood. Astringent tonics, hot water, substan- 
tial meat foods, so prepared as to be easy of digestion, are 
here indicated. City life in large centres is incompatible 
with the best hygienic conditions; a few weeks in the 
country or at the seaside speedily bring a restoration of 
the vital forces in these disorders, Inhabitants of large 
and busy cities, who live constantly at high pressure, re- 
quire a more sustaining diet than the residents of small 
towns or those who live in the country. City life tends 
directly to the development of the neuroses by its enervat- 
ing action upon the system. 

Generous wines, with quinia, are highly recommended, 
but a scientific dietary and the maintenance of proper 
hygienic conditions are more important elements in the 
treatment. 

In melancholia and the psychoses, tonics are especially 
indicated. Wines and cordials; pure air and pure water; 
proteid and carbohydrate food in proper proportions, along 
with drugs which stimulate digestion; and mental as well 
as physical rest, will do much toward reanimating and 
restoring these patients. 

In cases in which chlorosis is present we find the follow- 
ing train of symptoms : Marked exaltation or depression 
of spirits; emaciation, at times slight, at others well de- 
fined; paleness, often with a greenish tinge of the skin and 
mucous membranes; pearly appearance of the sclerotic; 
pufflness, most marked in the face; development of ca- 



THERAPEUTICS. 301 

cbexia; coldness of bands and lower extremities; full, soft 
and accelerated pulse; elevation of temperature; thirst; 
dryness of cuticle ; hysteria, melancholia; muscular debil- 
ity and a condition of general nervousness; irregular 
respirations; irregular neuralgic pains; spinal sensitive- 
ness ; palpitations ; a dry, barking cough ; dyspepsia, pyro- 
sis, a depraved appetite. Vomiting may be present and 
constipation is a frequent accompaniment, although, after 
the disease has existed for a considerable time, diarrhoea 
may be present. Irregular and excessive flushing of the 
face, an anaemic bruit at the base of the heart, and a 
venous hum in the neck may also be observed. In these 
cases the menstrual function is always affected, and may 
be entirely absent ; on the other hand, menorrhagia may 
exist. Menstruation may be painful, irregular, scanty, or 
of abnormal color ; leucorrhcea is very often present. 

The above is a brief resume of the symptoms of chloro- 
sis, a condition which is very frequently present in the 
class of diseases under consideration. The administra- 
tion of the various preparations of iron will usually give 
great relief. In many cases of chlorosis the disease is not 
recognized by the physician, because, as is often the case, 
the disturbances of menstruation, the dyspeptic symp- 
toms, and the nervous manifestations appear either sepa- 
rately or together before the peculiar pallid appearance of 
the skin has reached the point which proclaims the disease 
even to an inexperienced eye. In the treatment of chloro- 
sis, iron, arsenic, and strychnine are invaluable, and may 
be given according to the following prescription : 



3 Strych. sulph., gr. ^. 

Acid, arsenios., gr. -£$. 

Ferri reduct., gr. i. 

M. 



302 FUNCTIONAL NERVOUS DISORDERS. 

This in tablet form is an excellent preparation for 
chlorotic girls and neurasthenic patients generally. 

Iron should be administered at meals, as these are the 
periods when the gastric fluid contains the greatest amount 
of acid. In cases in which pyrosis or " water brash" is 
present, the iron should be administered between meals. 
When one preparation of iron has been used without ob- 
taining a satisfactory result, another should be tried. The 
treatment should be continued without intermission dur- 
ing the menstrual periods, and should not be discontinued 
until the disappearance of the chlorosis ; then there should 
be an intermission for about a month, when the treatment 
should be again taken up for three or four weeks. The 
following is a good combination : 

T$ Mass. Blaud, . . . . . . gr. v. 

Hydrarg. bichlor. , . . . . gr. g^. 

Strych. sulph., gr. ^. 

Acid, arsenios., gr. ^. 

M. 

One of these tablets should be taken after each meal. 
As a recurrence of the chlorosis is always possible, the iron 
treatment should be continued for some time, gradually 
increasing the intervals between the administrations and 
gradually decreasing the periods during which the iron is 
exhibited. In the treatment of nervous symptoms, due 
consideration must be given to the patient's constitution 
and temperament. In full-blooded and vigorous women, 
when anything approaching hysterical convulsions pre- 
sents itself, the administration of iron is likely to be pro- 
ductive of more harm than good ; while in other patients 
who are debilitated from loss of blood or other cause the 
nervous symptoms will very generally disappear with 
rapidity under the treatment by ferruginous preparations. 



THERAPEUTICS. 303 

In neuralgia, which is a very common symptom in chlo- 
rotic patients, and which in such cases changes its seat 
with remarkable rapidity, iron will usually prove of great 
benefit. This type of neuralgia is often very difficult to 
recognize. In cases of facial neuralgia, local applications 
should be combined with the internal administration of 
iron, and may consist of belladonna or chloroform ; some- 
times hypodermic injections of morphine may be given. 
In functional nervous disorders, while placing a due 
amount of reliance upon drugs, other agents must not be 
overlooked. The importance of a proper diet, strictly 
adhered to, cold or tepid baths, and a suitable form and 
amount of bodily exercise cannot be overestimated. With 
regard to bodily exercise, we may remark that while in 
some cases it is a valuable adjunct to the treatment, in 
others, in which neither iron nor any other medicinal 
agent will be of advantage, properly directed systematic 
exercises alone will effect a cure. 

Antispasmodic Agents. — Among the antispasmodic 
agents which are useful in the treatment of the nervous dis- 
orders of women, valerian occupies a very prominent posi- 
tion. In simulated disease in hysterical subjects, its value in 
large doses can scarcely be exaggerated. In cases in which 
vertigo is present, its administration is always indicated. 

Asafcetida may be prescribed in all cases in which vale- 
rian is suitable, but it possesses the disadvantages of an ex- 
ceedingly disagreeable odor and taste and a liability to 
cause purging, which make it a less desirable agent than 
valerian. In violent hysteria, and when constipation and 
hysterical colic exist, asafcetida has been found to be use- 
ful. It will give better results than valerian in nervous 
disorders of the digestive and respiratory tract. 

Camphor has been extensively used in almost all neu- 



304 FUNCTIONAL NERVOUS DISORDERS. 

rotic disorders. It is, however, more useful in the nervous 
symptoms accompanying fevers than in true neuroses. It 
has been highly extolled in the treatment of mania. Its 
greatest value is perhaps as an anaphrodisiac. 

Ether is both a stimulant and an antispasmodic, but its 
effect is transient. A few drops administered when pre- 
monitions of an hysterical fit are noticed, will usually 
abort the attack. In spasmodic and nervous affections 
unaccompanied by inflammation, it is very valuable. In 
spasmodic colic, nervous palpitations and headache, and 
during the paroxysms of spasmodic asthma, it will be 
found very useful, as it will, in fact, for many nervous 
symptoms arising in the course of almost any disease. 
Hoffman's anodyne is a good form in which to adminis- 
ter ether. For mental emotion or hysteria this gives 
prompt relief. It is of great temporary value in angina 
pectoris and in spasmodic asthma, but full doses must be 
given to produce the desired effect. In hysterical sick- 
headaches half -drachm doses should be given, or, combined 
with the ammoniated tincture of valerian, two-drachm 
doses every twenty or thirty minutes. All abdominal 
irritations, such as colic or diarrhoea, causing spasmodic 
contractions of the arteries of the lower extremities, which 
especially in children are often accompanied by a rush of 
blood to the head, are relieved by a few drops of Hoff- 
man's anodyne. When there is a deficient supply of 
blood to the lower extremities, spasm of the muscles, as in- 
dicated by painful cramps and flexion of the toes upon the 
soles of the feet, shows reflex irritation. Hysterical women 
are often victims of rumbling and gurgling in the bowels, 
and suffer from excessively cold feet, the result of arterial 
spasm from abdominal irritation. Two teaspoonfuls of 
Hoffman's anodyne is an efficient remedy. 



THERAPEUTICS. 305 

Oxide of zinc has been used in almost all neurotic affec- 
tions, and some authorities claim to have seen great benefit 
accrue from its use, especially in epilepsy. Taking all the 
evidence for and against it, however, its value is very 
questionable. The same remarks apply to the acetate and 
lactate of zinc. 

The oxalate and nitrate of cerium have been used in 
neuroses by Sir James Simpson, who affirmed that he had 
a great measure of success with them, especially in the 
vomiting of pregnancy. 

Reflex vomiting of cerebral origin, the vomiting of 
pregnancy, and seasickness are benefited by treatment 
with the bromides. In seasickness the dose used need not 
be large, but it should be accompanied by a goblet or two 
of very hot water. Used in this way they are very suc- 
cessful agents, but the hot water is the more important. 
Palpitation of the heart is benefited by them, when not de- 
pendent upon anaemia or gastric catarrh; but when due to 
either of these two conditions, rectification of the gastric 
disorders and the consequent enrichment of the blood are 
of primary importance. In insomnia, the hypnotic action 
of the bromides is well marked. They are often prescribed 
with benefit in alcoholic delirium, but the elimination of 
the poison by drinking hot water and the assimilation of 
nutritious food are of vastly more importance in the treat- 
ment. Where there is much anaemia the bromides are 
harmful, as they are especially liable to set up gastric 
catarrh if not properly administered. In melancholia and 
hypochondriasis they may sometimes be used with benefit, 
while again, in the same conditions, their exhibition may 
be harmful. Migraine of the congestive type is often 
markedly benefited by the use of the bromides, especially 

of the effervescent preparations. In the vascular neuroses 
20 



306 FUNCTIONAL NERVOUS DISORDERS. 

they often give marked relief; in morbid blushings and 
flushings occurring at the menopause, or whenever the 
local circulation is disturbed, the bromides are indicated. 
In the respiratory neuroses, reflex coughs of abdominal or 
pelvic origin, false croup, and reflex asthma, full doses 
usually give prompt relief. In ovarian neuralgia, and 
irritation, accompanied by menorrhagia or other functional 
disorder of the uterus, the exhibition of the bromides fre- 
quently removes these distressing conditions. 

Narcotics. — Opiates have been much used in the class 
of diseases under consideration, for the purpose of allaying 
spasm, relieving pain, and counteracting the insomnia 
which is often present. They appear to be of most use in 
cases of insanity, ecstasy, melancholia, and religious mania, 
but their unpleasant after-effects and the disagreeable 
dreams produced by their use, together with the danger of 
causing the opium habit, are facts which must receive due 
consideration from the physician and make him cautious 
in prescribing these agents. 

In hysteria, opium combined with an antispasmodic, 
such as valerian or asafcetida, is often most valuable. 
When great pain is present, such patients are very toler- 
ant of opium, and a larger dose than the usual one must 
be administered. The local application of opiate lotions 
is also helpful, and should not be neglected. 

Sometimes in chorea, moderately large doses of opium 
are productive of very great benefit. 

In neuralgias it was formerly the custom to use opium 
internally and to apply it externally to the affected part, 
but since hypodermic injections of morphine have come 
into general use, they have quite superseded the other 
forms of treatment. When the neuralgia is facial the 
application of a strong solution of sulphate of morphine to 



THERAPEUTICS. 307 

the gums and buccal surfaces of the cheek on the affected 
side will often prove most efficient. In these cases qui- 
nine should always be administered internally, as it will 
in great measure assist to retard the return of the neural- 
gia. In tic doloureux, which is an extremely obstinate 
affection, large doses of opium have always given more re- 
lief than any other method of treatment. 

In neuralgia, especially of the facial type, the internal 
administration of belladonna has been most favorably 
spoken of. It should be given in frequently repeated 
doses, to be reduced as the pain becomes less. Its use 
should be continued until all traces of the neuralgic pain 
have disappeared. In many cases it will be expedient to 
administer fairly large doses of the sulphate of quinine to 
prevent the return of the attack. The local application of 
belladonna has been followed by very satisfactory results 
in cases in which the affected nerve is superficial. In se- 
vere cases the part should first be blistered, and the bella- 
donna applied after the removal of the epidermis. After 
the disappearance of the pain, quinine should be adminis- 
tered. In the nervous colic which frequently occurs in 
hot weather and in tropical climates, belladonna has 
proved of signal service. Some practitioners claim that 
this drug has given gratifying results in cases of insanity, 
but other authorities assert that they have never seen any 
benefit from its use; wherefore it would seem that its 
value in these cases is not fully established. Belladonna 
is a powerful stimulant and tonic to the sympathetic nerve 
centres, especially those which have supervision over the 
involuntary muscular fibres. It is of the greatest value 
in functional disorders of such organs as contain these 
fibres, as for instance the alimentary canal from the phar- 
ynx to the anus, the genito-urinary passages, the heart, 



308 FUNCTIONAL NERVOUS DISORDERS. 

and the whole arterial system. In nervous women with 
globus hystericus there is spasm or paralysis of the 
oesophagus. This is usually relieved, by belladonna. In 
hysterical gastrodynia it is sometimes of much benefit. 
In chronic constipation resulting from uterine or ovarian 
irritation, it alone often corrects this condition. In reflex 
asthma one-fifteenth of a grain of atropine, injected hypo- 
dermically low in the nape of the neck, often affords 
prompt relief. The constipation of nervous women and 
hypochondriacs has been successfully treated by small 
doses of belladonna, which will often effect the desired 
result when powerful purgatives have failed. In these 
cases the best period for its administration is at bedtime. 
It may be added that abdominal massage properly given 
is in these cases a specific. In gastralgia and enteralgia 
belladonna has also been found useful. Where there is a 
tendency to constipation it may be given at mealtimes or 
at bedtime. 

In the uterine pains of neuralgic character occurring in 
chlorotic subjects, belladonna is a most useful agent. It 
may be used either in the form of a rectal or a vaginal 
injection ; if the former, about fifteen minims of the tinc- 
ture should be injected with a little water ; if the latter, a 
strong decoction should be employed, say about one ounce 
to three pints, and repeated twice or thrice daily. In the 
vomiting of pregnancy, the extract of belladonna, made 
into a thin paste by means of water, and applied with 
friction over the hypogastric region, has been found to be 
remarkably successful. After the friction a compress of 
wet lint, covered with gutta-percha tissue, or oiled silk, 
should be applied. Belladonna has also been successfully 
used for the same purpose in the form of applications to 
the cervix. In the salivation occurring in some neurotic 



THERAPEUTICS. 309 

patients, small doses of the sulphate of atropine have been 
used with good results. In spasmodic asthma, smoking 
the dried leaves of belladonna has given relief, often when 
all other agents have failed. If the patient has an insur- 
mountable objection to smoking, the drug may be adminis- 
tered internally, but, although some relief may be obtained 
in this manner, the results are by no means as satisfactory 
as those produced by the smoking. 

Dr. William M. Leszynsky, in a paper upon the use of 
atropine in the treatment of localized muscular spasm, read 
by him before the New York Neurological Society in Feb- 
ruary, 1891, says (and his remarks show the value of the 
drug in cases in which the spasm is of functional origin) : 

"In March, 1884, I reported a case of clonic torticollis 
successfully treated by the subcutaneous administration of 
the sulphate of atropine. The following is a brief synopsis 
of the case: Female, 21 years of age; unmarried; clonico- 
tonic spasm affecting the right sterno-cleido-mastoid mus- 
cle, of nearly two months' duration. 

"The initial dose was one-eightieth of a grain, which 
was daily increased in amount until, on the twentieth day, 
she was receiving nearly one-sixth of a grain (the maxi- 
mum dose), which was continued in the same quantity 
daily for four days, when recovery supervened. 

" No decided improvement was manifested until the in- 
jection of nearly one-sixth of a grain. All other treat- 
ment was deemed auxiliary to the atropine. In the 
discussion which followed, it was claimed that, as a num- 
ber of other remedies (galvanism, bromides) were used in 
conjunction with the atropine, it would be difficult to 
determine which effected the cure. From the close obser- 
vation of this case, I felt confident, and so expressed my- 
self at the time, that the recovery could be attributed to 



310 FUNCTIONAL NERVOUS DISORDERS. 

the effect of the atropine. Subsequently the long- wi shed- 
for opportunity presented itself, which enabled me to test 
the efficacy of the drug in a similar form of spasm, un- 
trammelled by the objectionable association of other reme- 
dies. I therefore take pleasure in submitting the history 
of the following case for your consideration and criticism : 

"Charles C, born in the United States, 37 years of age 
and a painter by occupation, presented himself for treat- 
ment June 2d, 1888. Three years previous, muscular 
spasm began on the right side of the neck, arising six 
weeks after an abscess had been opened at the angle of the 
jaw on the right side. The force of the spasm is increased 
by mastication and closure of the jaw, and it is more active 
upon mental excitement. He is frequently aroused from 
sleep by the severity of the paroxysm. 

" There is no complaint of pain, but only of numbness in 
the right lower lip. His occupation frequently brought 
him in contact with lead, but he never suffered from colic 
or paralysis. There is no history indicative of trauma or 
syphilitic infection. Formerly, alcoholic excesses. The 
bowels are constipated, but his appetite is good. 

" He was treated hj means of medicines and electricity 
for four months without relief. 

" He is a fairly nourished man of average height. There 
is well-pronounced clonico-tonic spasm affecting the right 
platysma, forcibly drawing downward the fascia about the 
chin and the lower angle of the mouth. 

" The clonic character of the spasm preponderates, and is 
almost constant. The muscle is hypertrophied to nearly 
four times its normal size, and its outline is distinct and 
well defined. There is an area of complete anaesthesia one 
centimetre and a half by three centimetres at the vermilion 
border of the lower lip, near the angle of the mouth on the 
right side, which extends inward over the mucous mem- 
brane and over the alveolar process in the lower jaw. 

" The mechanical irritability of the facial muscles is well 



THERAPEUTICS. 311 

marked. The jaw jerk is demonstrable. There is no 
apparent caries of the teeth. There is no abnormality evi- 
dent in other portions of the body. 

" Treatment. — A cantharides plaster was placed over the 
affected muscle. 

"June 9th. — One week has elapsed since treatment was 
begun, but there is no improvement in the spasm. The 
mechanical irritability of the facial muscles has diminished. 
He sleeps better. Injected y^-g- of a grain of sulphate of 
atropine into the platysma. 

"lOth.-Gr. Tfo. 

"11th. — Sleeps well, and the spasm is less frequent. 
Gr. Tiro- 

"12th. — Vertigo was complained of half an hour after 
the injection. He says he is very much better. The ex- 
aggerated mechanical irritability of the facial muscles has 
markedly decreased. There is also some abatement in the 
frequency of the spasm, which was formerly produced or 
aggravated by closing the jaw or turning the head to the 
left. 

"These movements can now be accomplished with im- 
punity. Sensation is returning in the ansesthestic area. 
Only one slight spasm occurred to-day. The tonic char- 
acter of the spasm has entirely subsided. Gave gr. -^ . 

"13th.— Gr. Jq- 

" 14th. — Spasm is induced by pressure over the alveolar 
process in the right inferior maxilla, in the locality of the 
second bicuspid tooth (which has been lost). Atropine, 

" 15th.— Gr. eV 

"16th. — No spasm since last note. Only slight vertigo 
after last dose. Gr. -^. 

"19th. — Has been receiving daily injections of gr. -^ 
without producing toxic symptoms. Injected gr. -£%. 

" 21st. — He did not call yesterday. No spasm since last 
note. Gr. -fa. 

"23d. — No attack. Says he is well. Gr. ^g. 

" 26th. — No injection since last note. Spasm has not re- 



312 FUNCTIONAL NERVOUS DISORDERS. 

turned. The most energetic effort fails to produce any 
spasmodic action in the platysma. Administration of 
atropine discontinued. 

"August 18th. — Reports to-day that he has remained 
free from spasm. 

" The successful treatment in this case extended over the 
brief period of two weeks, and was restricted to the daily 
administration of atropine. 

" The solution used was — 

1$ Atropinee sulph., gr. i. 

Aq. destil. , § i. 

M. 

" One minim of this solution represents -$fa of a grain of 
atropine. My method has been to give four minims (gr. 
T |o) at the first injection, and to be on the alert for consti- 
tutional effects. Upon discovering that there is no idio- 
syncrasy in regard to the drug, it is administered once 
daily, and the quantity gradually increased from day to 
day until the desired effect is produced or intolerance is 
established. 

" The production of severe constitutional symptoms is not 
an essential feature in this plan of treatment. 

"One of the experimental physiological efforts of the 
drug, when given in sufficient quantity, is to paralyze the 
motor nerves, first affecting their trunk. 

" I am not prepared to say whether the atropine relieves 
the spasm through its constitutional action and its ulti- 
mate paralytic effect upon the motor nerve trunk, or by 
its immediate local action. 

" It seems to me, however, that, by injecting the fluid 
directly into the substance of the muscle, it is not so 
rapidly absorbed, and thus has ample opportunity to act 
locally upon the intra-muscular nerve elements. There ap- 



THERAPEUTICS. 313 

pears to be no ground for the assumption that the atropine 
possesses an elective affinity for the hyperkinetic area after 
its absorption into the general circulation. This remedial 
measure deserves a fair trial in analogous cases before 
resorting to surgical procedures, such as nerve stretching 
or tenotomy, the results of which are not always encourag- 
ing. 

" The improvement in the following case of facial spasm 
seems worthy of note : 

"On the 29th of May, 1888, I was consulted by M. M., 
a widow, 50 years of age, who stated that for nearly a 
year the left upper eyelid has been tremulous. Facial 
spasm developed four months ago. It is worse in wet 
weather and upon mental excitement. The cause of the 
spasm is unknown. She has suffered from occasional ver- 
tical cephalalgia during the last two years. Climacteric 
three years ago. She received galvanic treatment for six 
months without any perceptible change. There is con- 
stant tremor in the lower segment of the orbicularis palpe- 
brarum, also frequent clonic spasm affecting all of the 
left facial muscles. There are no teeth in the left upper or 
lower jaw. They were lost during pregnancy. No ten- 
derness over the alveolar processes. No spinal tenderness. 
The pupils are small, but react normally both to light and 
in accommodation. Hypermetropia, 2 D. No fundus 
lesion. 

" She was kept under observation until June 9th, when 
she received the first injection of y^-g- of a grain of atro- 
pine. The needle was introduced deeply into the tissues 
of the face, near the exit of the facial nerve at the stylo- 
mastoid foramen. 

"June 10th. — The spasm is a little more frequent, but 
weaker. Gave injection of five minims. 

" 11th. — Face was flushed for nearly two hours after the 
injection. There is decided improvement. Til v. 

"12th. — Flushing of the face and dryness of the mouth 



314 FUNCTIONAL NERVOUS DISORDERS. 

and throat all of yesterdaj 7 afternoon. She says she is 
much better, and the improvement is evident. TT|,vi. 

"13th.— mvij. 

"14th. — Doing well. TUviij. (gr. ^). 

"15th.— mix. 

" 16th. — tt[x. Spasm in orbicularis palpebrarum is quite 
noticeable, but feeble. 

" 19th. — Has had daily injection since last note. Much 
improved. The only symptoms following the injection 
are flushing and headache, which subside in a few 
hours. 

" Since beginning the use of atropine I have never wit- 
nessed a well-marked facial spasm. The orbicularis pal- 
pebrarum is mostly affected, but not so much as formerly. 
Tremor has taken the place of the spasm in the other mus- 
cles, mxij. (gr. 4V). 

" 23d. — Daily injection since last note. 

" 30th. — She says she has an occasional spasm, as before, 
but neither so severe nor so frequent. TT[xv. 

"October 13th. — She reports to-day having discontinued 
treatment, and states that thus far the improvement has 
been permanent. 

" It is well known that, in this peculiar and obstinate 
affection with an obscure pathology, remissions occasion- 
ally occur independently of treatment. 

" The improvement, however, in this case was sufficiently 
encouraging to commend this method of treatment for 
further trial." 

Stramonium, which is very similar in its action to bella- 
donna, may be used in the same class of cases. When 
one fails, the other should always be tried, as many cases 
may be relieved by the one and not at all benefited by the 
other. 

In insanity and chorea, and especially in cases of mono- 
mania with hallucinations, stramonium has been highly 



THERAPEUTICS. 315 

extolled, but it is in spasmodic asthma that its value is 
most apparent. The powdered leaves should be smoked in 
the form of cigarettes, or in a pipe, mixed with equal parts 
of dried sage leaves. Inhalations of the drug are used but 
are much less reliable. In neuralgias the internal admin- 
istration of the tincture of stramonium has been found to 
be of great service. It should be given in small doses — 
four or five minims repeated every three or four hours. 
Plasters made of stramonium have also been used in the 
treatment of neuralgias, especially those of the scalp, and 
have many advocates, but it is only in transient and 
superficial neuralgias that they can be of any benefit. 

Hyoscyamus is a very valuable drug, with properties 
similar to those of belladonna and stramonium. It is most 
useful as a sedative in nervous disorders, and is of great 
value when given internally in the treatment of neural- 
gias. It may also be locally applied in cases in which the 
affection is transient and superficial. 

In hysteria its use has greatly benefited the patient, 
more especially when convulsions have occurred. 

Cannabis indica, or hashish, is a drug which deserves 
to be employed in functional diseases more often than is 
the case. It may be given when there is no acute inflam- 
mation present. In migrainous headaches it is a remedy 
of great value and also in neuralgia. Its principal effect 
is to ward off the attack rather than to stop it when pres- 
ent. I have a very favorable opinion of it as a preventive 
agent under these conditions. It is an excellent substitute 
for opium, causing none of the evil effects of the latter. 
In treating migrainous headache we should not forget 
that gastric irritation is usually the cause of the pain, 
and that relief of the stomach disorder usually causes 
a disappearance of the headache. Cannabis indica is of 



316 



FUNCTIONAL NERVOUS DISORDERS. 



value in some cases of hysteria, and may also be used 
sometimes for the relief of dysmenorrhea. 

The following combination is highly recommended by 
Dr. Henry J. Kenyon as a nerve tonic in chronic neural- 
gic headaches and other neuralgias : 



Zinc phosphide, . ' . 


gr. &• 


Ext. cannabis ind. , 


gr. i- 


Ext. nux vom., 


gr. h 


Sodium arseniate, 


gr. &■ 


Quinine sulph. , 


• gr- *. 


Ext. aconite root, . 


g r - Ttr 



One tablet should be taken at 10 a.m. and at 4 and 9 p.m. 
and the number increased by one tablet every week until 
four are taken three times daily; they should be taken 
steadily for three or four months. They act as an altera- 
tive to diseased nerves. 

Lobelia is an excellent agent in nervous asthma, and 
frequently gives much relief to patients who have received 
no benefit from the administration of either belladonna or 
stramonium. It is best given in the form of the tincture, 
in doses of from ten to twenty-five drops, three or four 
times a day. 

Aconite is a product of special value in neuralgias and 
nervous headaches ; it is also very useful in amenorrhea 
dependent upon the existence of a condition of spasm in 
the uterus. Three minims of the tincture should be given 
thrice daily. The following combination in tablet form 
has been found useful in acute attacks of tic douloureux : 



1$ Aconite amorph. , 


gr- *fo- 


Aatifebrin, .... 


gr. ij. 


Quin. mur. , 


gr. i. 


Arsen. chlorophos., 


gr- T¥0- 


Strych. mur., 


gr. 7 h>- 



Almost the only class of nervous diseases in which 



THERAPEUTICS. 317 

chloral has been used with any great measure of success 
is acute mania. In this condition it will quiet agitation 
and induce sleep. In melancholia and several other con- 
ditions its action is so depressing as to contraindicate its 
use. In asthma and in insomnia it may produce temporary 
benefit. Equal parts of chloral and camphor triturated 
together form a clear liquid, which, when painted over the 
surface at the seat of pain, is of great value in neuralgia. 

For the relief of nervous headaches the following for- 
mula has been found excellent : 

R Acetanilid, gr. iij. 

Camph. monobrom. , . ... gr. ij. 
Caffein cit. , gr. i. 

This is best used in tablet form, and may be repeated 
every two hours as needed. 

When much flatulence is present it is well to give 
as an antifermentative two grains of the salicylate of 
soda, combined with charcoal, ginger, and aromatics. 
This is useful when taken in tablet form an hour or two 
after meals, with a plentiful supply of water. 

Electro-Therapeutics. 

This branch of medical science is at present making 
such forward strides, is undergoing such rapid changes, 
and is of so great importance in the treatment of the 
diseases which we have been considering, that the reader 
is referred to special works upon the subject. Few agents 
are more useful in nervous disorders than electricity, 
but the limitations of this work do not permit of the 
extensive consideration of the topic which it deserves, 
while to treat it cursorily might be misleading and 
would certainly be unsatisfactory. 



318 FUNCTIONAL NERVOUS DISORDERS. 



Dilatation for Stenosis and Flexion of the 
Uterus. 

In many neurasthenic and hysterical women, this proce- 
dure may be necessary. Frequently nervous disorders are 
dependent upon chronic endometritis, obstructive dysmen- 
orrhoea, and sterility, and to remove the inflammation 
and the obstructions to menstruation and insemination, it 
is often necessary to dilate and straighten the uterine 
canal. The stenosis is very frequently at the internal os, 
and is caused by flexion of the neck on the body. This 
condition is the result of pelvic inflammation, subinvolu- 
tion, or hypertrophy, which forces down the uterus and 
the cervix against the posterior vaginal wall, thus deflect- 
ing the cervix while in a softened condition upward on 
the body, or flattening the end of it to a button-shape. It 
deforms the external os, causing it to become a mere slit. 

Schroeder * says : " Stenosis of the cervix may be con- 
genital or acquired. The congenital form sometimes in- 
volves the whole cervical canal, and is very frequent at 
the external os, which is much contracted ; seldom at the 
internal os. In the normal uterus (with the small cervix 
and the small external os of the undeveloped uterus we are 
not concerned at present) the vaginal portion is sometimes 
very long, hard, and gristly, and projects unusually pointed 
and conical into the vagina. On the point is the external 
os, so small as sometimes scarcely to be perceived, and in 
the speculum it is difficult to discover the small opening, 
and then often only by a drop of mucus protruding from 
it. Frequently the anterior lip projects and overlaps the 

* Karl Schroeder: " Krankheiten der weiblichen Geschlechtsor- 
gane," BerliD, 1881. 






THERAPEUTICS. 319 

posterior, so that the os is hidden as by a vaive." These 
are conditions of defective development. In the majority 
of cases of stenosis the obstruction is at the internal os, 
and is the result of anteflexion. Od passing the sound in 
these cases, it meets with an obstruction which is quite 
sensitive, due, probably, to inflammatory hyperaesthesia or 
irritability from flexion compression of the nerves at the 
angle. This obstruction may exist and there may still be 
no dysmenorrhcea. The internal os is occluded by inflam- 
matory swelling before dysmenorrhcea manifests itself 
from this cause, although sterility is the common result. 

Duncan * recommends as very successful in dysmenor- 
rhcea spasmodica mechanical treatment by dilatation with 
bougies ; the point he insists on is the stretching or dis- 
tention of the internal os, using in some cases as high as 
No. 12 or 13, corresponding to male bougies, but with a 
different curve. 

Sir James Simpson, of Edinburgh, maintained that 
stenosis of the internal os produces dysmenorrhcea and 
sterility, and devised a metrotome for cutting the constric- 
tion. 

There is no doubt that flexions are a very great cause of 
sterility, not only by mechanical obstruction, but also by 
producing secondarily strongly alkaline uterine and cervi- 
cal catarrhs, which destroy the vitality of the sperma- 
tozoa. 

Miiller f states that " conception may be rendered difficult 
by a flexion of the uterus. This pathological condition in 
the majority of cases implicates the narrowed portion of 

* J. Matthews Duncan: "Clinical Lectures on the Diseases of 
Women," 1882. 

•f P. Miiller: "Cyclopaedia of Obstetrics and Gynaecology," Vol. 
xi., pp. SQetseq., 1887, article "Sterility." 



320 



FUNCTIONAL NERVOUS DISORDERS. 



the uterine body; viz., where normally the uterine walls 
are in simple apposition they become firmly compressed, 
thus producing a stenosis of the uterine canal." 

The sharper, more acute the angle of flexion, the more 
certain the sterility; and, if the cervical canal is plugged 
with thick, tenacious mucus, there is no doubt of its being 
an absolute cause of that condition. Flexions of the uterus 
cause many reflex symptoms— vertigo, headache, neuras- 
thenia, nausea and vomiting, and very many other hys- 
tero-neuroses. These are only relieved by dilatation and 




Fig. 27. 



Fig. 28. 



proper intra-uterine and extra-uterine treatment. Flex- 
ions and endometritis are very often the exciting and 
direct cause of hystero-epilepsy — a fact which I have 
demonstrated by several cases in my own private practice. 
A number of different forms of uterine dilators have 
been devised, but about all of them — like Sims', Ellinger's, 
and Palmers' — diverge laterally, and dilate the cervical 
canal at the internal os in a direction where there is very 
frequently no constriction. The advantages of this form 
of instrument over the ordinary lateral dilators is best 
shown by an article by Dr. Graily Hewitt, in the Annals 



THERAPEUTICS. 



321 



of Gynaecology of 1888, from which the above two illus- 
trations are taken. They represent a well-marked case 
of acute anteflexion, and demonstrate of themselves the 
correctness of dilating the internal os and cervical canal in 







Fig. 30. 



an antero-posterior direction. He 
says, referring to Fig. 27 : " The 
uterine cervical canal is here hardly 
visible at the centre and upper part 
of the cervix, owing to the closeness 
of apposition of the anterior and pos- 
terior walls, which closeness is due, 
as is manifest, to the presence of the 
flexion. In Fig. 28 is shown another 
illustration of the same uterus, but 
the cervical canal on one side (the 
right) is opened out by traction of 
two threads. ... It is thus made 
evident that the cervical canal is not by any means de- 
stroyed. The interesting fact becomes evident that the 
21 



Fig. 81. 



322 FUNCTIONAL NERVOUS DISORDERS. 

canal is unusually widened from side to side at the same 
time that it is so narrowed from before backward that it 
is hardly visible when the canal is in its untouched, flexed 
state. In this particular case the part of the uterine canal 
most affected by the flexion is just below the internal os. 
The bending of the uterus produces a curvature of the 
canal, which operates particularly on the canal for about 
three-quarters of an inch. In this space the canal is ex- 
cessively wide from side to side, but excessively narrow 
from before backward, and it is manifest that the lateral 
wideninng, as well as the antero-posterior compression and 
narrowing, result from the shape of the uterus. The in- 
ference also follows that exaggeration of the degree of the 
bending of the uterus would have the effect of increasing 
the compression of the uterine canal. It is not easy, look- 
ing at this specimen, to avoid the conclusion that the es- 
cape of menstrual fluid and menstrual debris from the 
uterus must have been very difficult so long as the uterus 
remained flexed to its present degree." 

The accompanying drawings demonstrate the result of 
flexion in a simple rubber tube : Fig. 29 represents a side 
view, showing the compression in the direction of the 
arrows, while Fig. 30 is a front view, showing the lateral 
widening. The lateral dilators cannot be made to dilate the 
cervical canal in its antero-posterior or conjugate diame- 
ter with any sort of satisfaction, and lateral flexions are 
extremely rare. The instrument devised has handles 
which are most convenient to manipulate, with the regis- 
tering guide well out of the way of the fingers, and is 
graduated in inches and in centimetres, so that one can 
exactly determine the amount of dilatation and keep a 
record of it if desired. The intra-uterine portion of the 
blades is but two inches in length, as that is all that is 



THERAPEUTICS. 323 

necessaiy. The danger of injuring the fundus uteri is 
thus avoided. It gives the greatest dilatation at the inter- 
nal os, where it is most needed. Of the lateral dilators, I 
think Sims' is the best. 

As to what constitutes stenosis. 

Peaslee * says : " In the imparous woman the narrow- 
est point of the cervical canal — viz., the internal os — is, 
when opened by passage of the menstrual fluid, an ellipse 
whose conjugate and transverse diameters average, re- 
spectively, one-sixth and one-eighth of an inch, its area 
corresponding very nearly with that of a circle one-seventh 
of an inch in diameter. The external os, also elliptical 
when moderately dilated, has diameters averaging one- 
fourth and one-sixth of an inch. It thus has an area ex- 
actly twice that of the internal os, and equaling that of a 
circle one-fifth of an inch in diameter. In the parous 
woman the size of the external os varies within quite ex- 
tensive limits, since it is exposed to so many of the acci- 
dents of parturition, while the internal os is more nearly 
uniform." He finds, as a rule, the lowest average diame- 
ter in parous women who are neither sterile nor have 
dysmenorrhcea to be about one-fifth of an inch, or a little 
less, at the inner os, presenting nearly twice the area, of 
that of the imparous woman ; the external os, as a rule, to 
be about one-fourth of an inch in diameter. He believes 
that in the treatment of dysmenorrhcea and stenotic steril- 
ity these dimensions will be found sufficient in many 
cases : 

Imparous. — The internal os equals a circle one-seventh 
of an inch in diameter; the external os equals a circle 
one-fifth of an inch in diameter. 



* E. R. Peaslee : Transactions of the New York Academy ot 
Medicine, 1876, p. 428 et seq. 



324 FUNCTIONAL NERVOUS DISORDERS. 

Parous. — The internal os equals a circle one-fifth of an 
inch in diameter ; the external os equals a circle one-fourth 
of an inch in diameter. 

The performance of trachelotomy is now comparatively 
rare. There are many cases of conoidal cervix and ante- 
flexion in which Sims' sagittal incision may be performed, 
but it is better to try the milder and safer method of dila- 
tation first. 

Coe * says : " That the incision of the cervix for steno- 
sis is not an entirely harmless procedure is evident ana- 
tomically as well as clinically. The proximity of the 
peritoneum and the rich network of veins which lies in 
the muscular coat of the uterus renders the danger of peri- 
tonitis and septic absorption no imaginary one. The in- 
dications are clearly to make the incision as limited in 
length and depth as possible, and to practise rigid anti- 
sepsis." Bilateral incision is obsolete as an operation ex- 
cept in cases of conical cervix and pinhole os, and then 
simply as preliminary to dilatation. 

In the treatment of these cases we frequently find the 
uterus tender, with an almost imperforate cervical canal, 
swollen and occluded by tenacious mucus. It is necessary 
to have the uterus and adnexa prepared for the operation 
of dilatation by the usual treatment for removing inflam- 
matory condition, i.e., hot- water injections, astringent 
and detergent applications, boroglyceride, boric acid, tam- 
pons, etc. (Boroglyceride, an excellent preparation, was 
first introduced into this country from England by the 
late celebrated J. Marion Sims, where it was first used by 
a Mr. Balfe for preserving game.) On the table or cabi- 
net at the operator's side there should be, besides instru- 

* H. C. Coe: "American System of Gynaecology," vol. i., p. 151. 



THERAPEUTICS. 325 

ments, solutions of carbolic acid, bichloride, etc., a small 
porcelain, china, or glass dish containing cotton tampons 
soaked with boroglyceride and glycerin, and others dry. 
If they are not ready prepared, it causes considerable delay 
while the patient is on the table, which is unpleasant. 
After cleansing the cervix and vagina by mopping them 
with wet absorbent cotton, a double tenaculum is hooked 
into the anterior lip of the uterus, and it is drawn down- 
ward gently. With a hypodermic syringe, to which a 
silver intra-uterine pipe is attached, about thirty minims of 
a four-per-cent. solution of cocaine are injected into the 
uterine cavity, and the external os is plugged for a few 
moments with absorbent cotton. This gives great relief, 
particularly in acute and subacute endometritis with pelvic 
pain. After a few moments the dilator can be inserted 
and the canal dilated. In some cases it is necessary to pass 
conical cervical bougies before the dilator can be used. 
Of the usual forms, Peaslee's are inflexible, being of 
steel, and Hanks' are of hard rubber; two sets have 
been made, one of block tin and the other of copper, which 
are flexible, and can be moulded without trouble to the 
curves of the uterine canal. They are to precede the 
dilator when the canal is too small for its introduction. 
The block-tin sounds can also be used as obturators for in- 
serting the tracheal cannula. Ordinarily, half an inch is 
as far as dilatation should be carried. The patient should 
be in the Sims position. The operation can be done in 
many cases at the physician's office, but the uteri of some 
women have a habit of getting up a severe inflammation 
on very slight provocation, so it is safer to do the operation 
at the patient's home, and then with all antiseptic precau- 
tions. The instruments are to be washed in hot soap water 
to remove adherent mucus, and then in clean water, dried, 



326 



FUNCTIONAL NERVOUS DISORDERS. 



and passed through the flame of a spirit lamp, thus destroy- 
ing all germs, which boiling water does also. It does not 
discolor the instruments or "give them the blues," and 
they are finally placed in a three-per-cent. carbolic-acid 




Fig. 32. 

solution. In rare cases, when an in- 
cision is required at the internal os on 
account of the fibrous band or induration 
at the compressed angle of flexion, I have 
had a knife made with a metallic handle 
flexible below the blade, yet strong enough 
to resist any ordinary pressure for cut- 
ting-purposes. It is one-eighth of an inch 
broad at the base and one-sixteenth near 
the point, with a rounded point and back. 
A Sims or Emmet intra-uterine knife can 
be used, but they are much more expen- 
sive. After the blades of the dilator 
have been sterilized by passing them 
through the spirit flame, they are well 
greased and introduced. The handles are 
pressed gently and slowly, until the guide 
shows that half an inch, or a little over 
a centimetre, separates the blades. After cleansing the 
uterine cavity with an antiseptic, the intra-uterine stem is 
inserted and allowed to remain, the patient drawing it 
away by the silk thread if it causes any irritation. The 
stem (Fig. 32) has been modified by giving it a retaining- 



Fig. 33. 



THERAPEUTICS. 327 

swell, which adapts itself to the normal shape of the cervi- 
cal canal between the external and internal os and pre- 
vents it from slipping out if the proper size has been used. 
The principle involved in the intra-uterine stem is the same 
as in Dr. O'Dwyer's tubes for stenosis of the larynx, from 
which the idea of the retaining-swell and the perforation 
for the thread for its withdrawal was copied. The special 




Fig. 34.— Stenosis Case. 

forceps (Fig. 33) for introducing the stem holds it very 
firmly during its insertion. Messrs. Tiemann & Co. have 
put the instruments in, a case (Fig. 34), which also contains a 
rather heavy uterine probe to determine the direction of the 
canal. One is led to believe that the treatment of the fore- 
going conditions by dilatation is both rational and scien- 
tific. It is of course applicable to chronic cases only, and 
is a delicate procedure, requiring skill and good judgment. 

Cold. 

Cold acts on the vasomotor system as a neurotic irri- 
tant. As a tonic it produces a shock which, if not too 
great, is always followed by a reaction. This exercises 



328 FUNCTIONAL NERVOUS DISORDERS. 

the system, and thus tends to improve the nutrition and 
strengthen the body, or the part to which it is applied. It 
is a tonic in cases of weak circulation and feebleness of mus- 
cular power. It strengthens the heart and the arteries. 
It improves the digestion. During a cold bath, be it dip, 
shower, or sponge, great care should be taken that the 
patient does not become exhausted by its too long continu- 
ance. Five minutes is a sufficient length of time for any 
one. Reaction should be favored by massage and the use 
of the flesh brush. 

In migraine with dilation of the temporal artery and 
congestion of one eye, in cerebral congestion from sun- 
stroke, strong coffee, or tea, and in nasal hemorrhage 
great relief is often obtained by cold applications to the 
nape of the neck. Cold acts as a styptic by lessening the 
calibre of the arteries through its irritant effect upon the 
vasomotor nerves. By its irritation of the afferent nerves 
it causes not only a variation in the calibre of the vessels 
of the surface of the part to which it is applied, but also in 
all the arteries directly beneath that part. When the 
organs of the body are in pairs and perfectly symmetrical, 
as is the case with the eyes, cheeks, ears, hands, and feet 
(the kidneys, testicles, and lungs are not), any variation in 
the calibre of the vessels of one will cause a like variation 
in the calibre of the vessels of the other. Variations also 
in the calibre of the vessels of certain parts of the body 
are attended by corresponding changes in the arteries of 
certain other parts. These associations have been deter- 
mined empirically ; thus, the interdependence of the con- 
dition of the circulation of the feet, the abdominal and 
pelvic organs, and the pharynx, as well as that in the nape 
of the neck with the arteries of the brain and face, is well 
known. Dr. William M. Thomson, of New York, has in 



THERAPEUTICS. 329 

his lectures noted the laws of the vasomotor s} T stem, and 
their response to the action of cold. 

An ice bag or ether spray applied to the epigastrium 
stops haematemesis. 

Holding a piece of ice in one hand will check bleeding 
in the other. A cold footbath will arrest metrorrhagia, as 
will also ice rubbed against the inner aspect of the thighs 
and across the abdomen. In post-partum hemorrhage the 
cold should be applied by means of the ether spray, for the 
sudden and intense impression which it makes causes 
effectual uterine contraction without chilling the patient. 

When the ether is not available, ice water may be 
poured from a moderate height, but this is rarely, if ever, 
necessary. Slapping the thighs and abdomen with cloths 
or towels wrung out in ice water is more convenient and 
in every way better. 






330 FUNCTIONAL NERVOUS DISORDERS. 



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LITERATURE. 331 

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332 FUNCTIONAL NERVOUS DISORDERS. 

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PREFATORY NOTE TO THE APPENDIX. 



The study of a subject is simplified and made 
more interesting when the verbal descriptions are 
supplemented by illustrative charts, plates, or dia- 
grams. Such devices assist in clearing up any 
obscurities in the text and are often of value in 
medicine in obtaining a correct diagnosis. The 
author has devised the following series of charts 
with the hope that they will serve a good purpose 
in illustrating some points in a rather obscure yet 
important branch of medical science. 



CHART I. 



• 



Hysterical Aphonia 
Apncea 
Dysphagia 
" Laryngismus 

" Strangulation 

" Suffocation 



Globus Hystericu 



Hemiplegias 



Contractu! 



Paraplegias 



Contractures 




: Mental Depression, Loss of 
Memory, Excessive Irri- 
tability, Wakefulness, In- 
I tense Lethargy, Day 
I Drowsiness or Narcolep- 
sy, Morbid Fears, Hyp- 
notism, Trance, Catalep- 
sy, Somnambulism, 
Neurasthenia. Anaesthe- 
sias, Hystero-Epilepsy or 
Hysteria Major, Melan- 
cholia, Mania 



Joint Neuroses 



CEREBRAL REFLEX NEUROSES 



CHART II. 



Hyperchlorhydria 
(A Primary Neu- 
rosis in Melan- 
cholia and 
Hvsteria) 



Dyspepsia I 
Diarrhoea \ 
(From Mental 
Emotion) 



Amenorrhea 
(Due to severe 
Mental 
Disturbances) 




Anachlorhydria 
(A Reflex in the Hys 
terical and the 
Neurasthenic) 



Intermittency 
Irrepularity 
Palpitation 
Bracliyciirdia :) 
Tachycardia U; 



v Enuresis 
I Polyuria 

(Reflexes from Men- 
tal Excitement) 



CEREBRAL REFLEX NEUROSES-Continued 



CHART III. 



SPINAL REFLEX TENDERNESS ARISES USUALLY FROM IRRITATION IN THE DIGESTIVE TRACT— FROM 
MENTAL EMOTIONS; POISONS OF VARIOUS FEVERS-FROM UTERINE DISORDERS. 




Cervieo-occipital pain 

(In Uterine Disease) 



f Reflex tenderness of Cer. 
vical and Upper Dorsal 

I Spine frequently accom- 
panies Gastralgia, Nausea, 
Vomiting, and Stomach 
Disease of different types— 
Ulcus and Hypersecretion 
of Hydrochloric Acid — Pain 
is between the Shoulder 
Blades— The Upper Extrem- 
ities may also be affected— 
This may be from direct Ir- 
ritation of the Cceliac Gan- 
glia of the Sympathetic 



Pains and Inflammatory 
conditions of the Lower 
Abdomen, Bladder, Genital 
Organs , and Lower Extrem- 
ities cause Reflex Spinal 
Tenderness in this region- 
Lower Dorsal and Lumbar 
— Most common in Uterine 
Affections— Endometritis 



SPINAL REFLEX NEUROSES 



341 



CHART IV. 



Ringing, Paroxysmal Cough ■_ 

(Dependent on Pregnancy) \ 



Asthma 
(From Uterine Retroflexion) 



Singultus ) 
Hiccough J 
(Fr»m Irritation in Digestive 
Tract) 




./ Bronchial Irritation 

(Due to Chronic Gastrie 
Catarrh) 



•- 1 Unilateral Perspiration 



* Cheyne-Stokes Respiration 
(From Pelvic Disease) 



BRONCHIAL REFLEX NEUROSES 



CHART V. 



Stomachal Vertigo 



Asthenopia ) 

) 'inmess of Vision 
Ttosis ) 

(Reflex from Digestive and 
Uterine disorder ) 



Angeio-spastic Mi- 
graine, a com- 
mon Gastric Neu- 
rosis—}! i g r a i n e 
and Toe Cramps, 
frequent an d i nt er- 
ehangeable symp- 
toms re suit in 
from indigestion 



Hay Fevei 



Reflex 

from 

Gastric 

Diseafe 



Dysmenorrhcea 
(Reflex from Chronic 
Gastric Catarrh) 



Fingers Anaesthetic or 

Neuralgii- 

(So-called "wind 

pains") 




Gastric Headache— Frontal 



^ Giant Urticaria, or Anpreio- 
• neurotic CEdema of Larynx 
( and Dorsum of the Hand 
(Due to Chronic Indigestion) 



Asthma 

(Reflex from Gastric 
causes) 



Angina Pectoris 
and Pseudo-An- 
gina, with Left- 
Arm Cramps 
A naesthesia 
Neuralgia 
t Palpitation 
(From Gastric Irri- 
tation)— 



Angeio-spastic 

Cramps in the 
Can , Leg Ache 

Gas iro-intestinal 
{ Neuroses— Com- 
i mon in Cholera, 
| Diabetes, etc. 
I Sharp pains in the 
I calf 
(Frequently due to 

Indigestion from 

strong coffee) 



GASTRIC REFLEX NEUROSES 



345 



CHART VI. 



Headaches {. 
Uterine Origin ) 



Swelling of 
Face, Arm, and >• \- 
Hand ) ■ 

(A Mensti*ual Neu 
rosis) 

Ovarian Hyper- 
esthesia, caus- 
ing Hyftero- 
epilepsy— If 
Inflammation 
is severe the 
pain is in- 
cr eas e d by 
pressure 



Diminution of ] 
secretion of ! 
Hydrochloric | 
Acid J 

(Reflex from Men- 
struation— E. 
Fleischer) 



Tingling of the 

Fingers and 
Swelling of the y jg 
Ball of the 
Thumb 
(A menstrual Neu- 
rosis) 



Excessive Secre- ) 
tion of Hydro- - 
chloric Acid 
( ^ Reflex after 

Coitus— M. Gross) 



Pain in Heel 
(Reflex from 
Ovarian Disease) 




( Pharyngeal 
■< Congestion, 
( Change of Voice 
(Witn Puberty) 



Neuralgia, Uterine 

(Common 

in Pregnancy) 



f Asthma, ] 

Uterine j y 

I Dyspnoea, ! » 

I Uterine [ g 

Cough, * 

[ Uterine J 

Quiverings o f 
Abdomen, Gas- 
tric Flatulence, 
Pyrosis, Acidity, 
Dyspepsia(Uter- 
ine), Epigastric 
SwellingorTym- 
panitic Disten- 
tion, ^ausea and 
Vomiting (con- 
stant), of Men- 
struation and 
Pregnancy, 
Faint ness, An- 
orexia, Bulimia. 
Belching (ac- 
companying 
Menstrual Con- 
gestion, Morbid 
Appetites or 
. Cravings) 



■-. Wrist Pains 

(From Ovarian 
Disease) 



Hystero- 
Neuioses of the 

Joints 
Hip 
Knee 
Ankle 



( Contractures of 
( the Toes 
(Accompanying 
the earlier Men- 
strual periods) 



HYSTERO-NEUROSES 



347 



CHART VII. 



Salivation, or Hypersecretion 
(Reflex from Menstruation, and 
Early Symptom of Pregnancy) 



Thyroid Enlargement 
(From Uterine Irritation) 

Mammary Swellings 
(Keflex from Ovarian or Utei 
ine Disease) 
Mastodynia. or Neuralgia Mam- I 
ma? (Menstrual) ( 

Congestion of Mammary Glands 
(Keflex from Menstruation, | 
or Concept ion) J 



Hypersecretion of Gas- 1 
trie Juice, and Hyper- - 
chlorhydria ) 



A Sensory Neurosis, Gland- 
ular— (Ewald) 



Hepatic Congestion and Jaundice 

(Reflex from Disturbed 

Emotions) 



Gall-Ftone Colic causes Reflex 
Temporary Hypochlorhydria 




( Suppression of Secretion of 

/ Parotid Gland 
(Due to reflex from Diseased 
Ovary, and Parotiditis c.i uses re- 
flexly, through Sympathetic, a 
painful oophoritis) 



( Seborrhea and Axillary Per- 
( spiration 

(Reflex from Indigestion) 



Renri Calculi 

(Cause Hvperchlorhydria 
R.fiexly) 



( Excessive Perspiration of Hands 
"( and Feet 
(Reflex from Digestive Disorder) 



Many of the Glandular Neuroses 
have been classified unuer other 
headings, such as Dermal, In- 
testinal, Renal, etc. 



GLANDULAR REFLEX NEUROSES 



CHART VIII. 



Retinal Hyperesthesia 
Anaesthesia 
(Common in Indiges- 
tion from Coarse 
Vegetable Food) 

Asthenopia 

(From Chronic Gastric 
Catarrh) 



Ptosis 
(Due to Liver 
Disorder) 



Mydriasis (Intestinal 

Parasites) 
Myosis (Constipation) ) 



Mouches Volantes 
(From Endome- 
tritis and Pelvic 
Cellulitis) Also a 
Renal Reflex (?) 



Hemeralopia (Night 

blindness) 
Nyctalopia (Day-blind 

ness 

(Menstrual Neuroses ;') 




Amaurosis (Menstrual) 
Amblyopia " 



( Amaurosis (Hysterical) 
( '" (Puerperal) 



( Strabismus (Hys- 
( tericai) 
(Due also to Worms) 



( Disturbances of 
I Accommodation 
(Due to Indigestion) 



Dimness of Vision 

(From Abdominal 

and Pelvic Disease) 



Photophobia 

(From Uterine 
Disease) 






REFLEX OPHTHALMIC NEUROSES 



351 



CHART IX. 



Anaemic roarings 
(Keflex from Uter- 
ine Polypoid 
growths) 



Neuralgia of ) 
Aural Serves J 
(Reflex from Preg- 
nancy) 




f Cracklings, 
! whistlings, loud 
] explosions like 
I pistol-shots 
(Reflex from Uter- 
ine or Gastroin- 
testinal Disorder) 



( Puffing, like 
•s that of a start- 
( ing locomotive 
(Reflex from Ova- 
rian Disease, com- 
mon as an Aura 
in Hystero- 
epilepsy) 



REFLEX AURAL NEUROSES 



353 



CHART X. 



Chloasma a n d 1 
Sallow Com- ^ 
plexion ) 

(Due to Faecal Im- 
paction) 



Pruritus Nasi 
(Due to rectal Ir- 
ritation, from 
Worms or Haem- 
orrhoids; 



Chronic Redness 

(Due to Uterine 
and Digestive 
Derangements) 



Hyperesthesia ) 

Anaesthesia > 

Perverted Sensibility ) 

(Due to Genito-Urinarj 

or Gastro-Intestinal 

Disturbances) 



BS5 }*— » 

HaBmorrhagic Perspira- , 
tions occurring at J 
Menses 



Urticaria 

Hives 

Nettlerash \ 

(From Ingestion 

of Shellfish and 

other Indigestible 

Foods) 




f Erythema Uteri- 
! mini 

] Chloasma Uteri- 
L nuin 



fAcne Rosacea, 
with Nasal Red- 
ness, Eruptions 
(Due to Gastric 
Disease) 



! Pigmentation of 
Areola 
(Reflex from Preg- 



■3 f Pruritus (From Diges- 
s- ', tive Disorder) 
% \ Flushes ) From Di- 

u Perspirations - gestive 
O (.Seborrhoea ) or Uter- 
ine Disorder 



Abdominal Chlo- 
asmata or the 
Brownish Discol- 
oration of Preg. 
nancy 



Herj>es of Pudenda 
(Due to Metritis) 



( Prurigo of Anus 

( and Vulva 

(Due to Obstruction 
of Portal Circula- 
tion from Conges 
tion of Liver) 
Severest at Meno- 
pause 



REFLEX DERMATIC NEUROSES 



355 



INDEX 



Abdomen almost black, 152 
Abdominal flushing, 61 
Accommodation, disturbances of, 

128 
Achromatopsia, 197 
Acne rosacea, 150, 152, 153 
Aconite in neuralgias and nervous 

headaches, 316 
Affections of microbic origin, 253 

of the spinal cord, 36 
Alexander's operation, 105 
Alimentation and hygiene, 269 
Alkaline baths, 156 
Amaurosis, complete or incomplete, 
164 

gravidarum, 128 

hysterical, 128, 159 

transitory, 128 
Amblyopia, 128, 197 

hysterical, 129 

transitory, 128 
Amenorrhoea, 27 

aconite in, 316 
Ansemia, 5, 139, 157, 252 
Anaemic headaches. 235 
Anaemic roaring, 137 

unilateral, 138, 
Anaesthesia. 27. 197 
Analgesia, 196 

Angeio-neurotic oedema, 77, 82 
Angina pectoris, 52, 124 
Animal food, 293 
Anorexia at menses, 89, 91 
Anorexia, description of 178 

hysterical, 178 
Antispasmodic agents, 303 
Anuria, 96 
Aortic plexus, 22 



Aphonia, hysterical, 27, 31, 165 
Apncea, hysterical, 27, 29 

reflex, 10 
Apoplexia, 130 
Arnold, 255 
Arsenic, 156, 299 
Arthralgias in uterine disease, 16 
Arthropathies, 80 
Articular reflex neuroses, 144 
Artificial production of the meno- 
pause, 73 
Asafcetida, 303 
Assimilation, 291 

imperfect, 273 
Asthenopia, 128, 129 
Asthma, 5, 306, 316 

hysterical, 166 

spasmodic, 309 
Ataxia, forms of, 132 
Atrophy of cheek, 131 

progressive muscular, 132 
Atropine in localized muscular 
spasm, 309 

in reflex asthma, 308 

in salivation, 308 
Auditory nerve, 138 
Aura hysterica, 194 
Aural reflex neuroses, 137 

symptoms and abdominal cav- 
ity, 138 

symptoms and chest disease. 138 
Australian blight, 79 
Autoinfection a cause of symptoms, 
137 

Bacon, 181 

Bacteria, 259 

Bacterial development, 260 



357 



358 



INDEX. 



Bactericidal properties of blood 

serum, 261 
Bacteriological origin of disease, 252 
Barker, 7 
Basic malady, 252 
Bath, practitioners at, 256 
Belching and vomiting accompany- 
ing menstrual congestion, 89 
Belladonna, 307 

in globus hystericus, 308 
Bichromate of potassium in bromi- 

drosis, 127 
Bidder, 255 
Bladder, 4 

functional disturbance, 98 

neurotic disturbance, 108 

treatment, 109 
Blepharospasm, hysterical, 164, 165 
Blue hysterical oedema, 176 
Blurring of vision, 130, 188 
Boix, 176 

Boldt on cardiac neuroses, 7 
Borborygmus, hysterical, 166, 194 
Boulimia. 89 

Braithwaite on codeine, 83 
Briquet, 189, 194 
Brissaut, 179 

Bristowe on hysteria, 159, 160 
Broad conception of disease, 252 
Brodie, 146 

Broken-down constitutions, 259 
Bromides, 305 
Bronchial and cardiac neuroses 

often combined, 85 
Bronchial hystero-neurosis, 87 
Bronchial reflex neuroses, 85 

causes of, 85 
Brunton on condurango, 299 
Burning sensations of tongue, 141 

hysterical origin of, 141 

Cafe noir, 298 
Caffeine, 298 
Calculus, 4 
Calumba, 299 
Camphor, 303, 317 
Cannabis indica, 315 
Cardiac disease, 5 

irritations, 27 

neuroses in connection with 
ovarian and uterine disease, 7 



Cardiac palpitation, 27, 194 
Cardiac reflex neuroses, 42 

dependent on digestive disorder, 
43 
Cardiac weakness, 252 
Cardialgia, 163 
Catalepsy, 27, 90, 215. 221, 222 

in melancholia, 223 

table, 223 

transient, 181 
Cataleptoid state, 114, 221, 222 
Catarrh, symptomatic uterine, 3 
Catarrhal states, 4, 252, 279 
Causative factors in reflex disturb- 
ances, 4 
Cerebral anaemia, 239 

excitement, 238 

hypersemia, 239 

irritations, 10 

neuroses, 10, 27 
Cerebro-abdominal neuroses, 99 
Cerebro-spinal nerves, 17 
Cerumen, impacted, 4 
Cervical induration, 90 

spine, 37 

sympathetic, 130 

tenderness, 37 
Charcot, 163, 184, 187, 190, 192, 197 
Change of climate, 60 
Cheyne-Stokes' respiration, 85 
Chloasma, 98, 153 

uterinum, 151 
Chloasmata, symptomatic, 150, 151 
Chlorosis, 90, 300 
Choking, hysterical, 165 
Chorea, general, 29, 165, 306, 314 

major, 242 

minor, 240 
Chromic acid in hyperhidrosis, 127 
Cinchona preparations, 298 
Cleanliness, internal, 260 
Climacteric changes, 74 
Coccygodynia, 113 
Cohn on uterus and eye, 132 
Cold, 327 

Coldness of extremities, extreme, 50 
Colic, 99 

Collins on angeio-neuroticcedema,78 
Colonic flushings, 99 
Condurango, 299 
Congestion in globus hystericus, 11 



INDEX. 



359 



Constipation, 15, 108, 270, 308 

during intermenstrual period, 98 
during menstruation, 98 

Constitution, run down, 2 

Contracted chest, 252 

Contractures, 159, 196 
causes of, 174 
general, 168 
treatment, 168 

Convulsions with dysmenorrhea, 
220 

" Convulsionaires," 236 

Copious water drinking, 254 

Corpulence, 287 

Cough, hysterical, 166 

Cramp in the head, 247 

Cramps, muscular, 8 

Cranial cavity, irritations in, 20 

Dana, 243 

Debility, evidences of, 107 
Delirium of hysteria, 179 
Delusions, fixed, 27 
Denis, 254 
Deprat, 171 

Dermal reflex neuroses or derma- 
toses, 149 
Dermatologist, 6 
Dermato-neurosis, menstrual, 153 

treatment, 155 
Dermatoses, 12, 50, 98 

acne rosacea, 153 

chronic urticaria, 150 

reflex, 79 
Diabetes, vasomotor disorder in, 64 
Diagnosis of disease, 5 
Diaphragm, irritation of, 40 
Diarrhoea after menstrual period, 98 

preceding menstrual period, 98 

reflex or nervous, 5, 27, 100 
Diet of neurotic patients, 272 
Dietetic treatment, 271 
Digestive disease, 6 

disorder, a common symptom 
of, 82 

disorders at menopause, 8 

disturbances in cardiac neu- 
roses, 45 

organs, 4 
Dilatation of uterine cervix, for 

stenosis, 318 



Dimness of vision, 128 
Diruf. 257 

Disease mimicry, 147, 181 
Diseases, organic, of nervous sys- 
tem, 12 
Disturbances of vision, 129 
Donovan's solution, 156 
Drowsiness during the daytime, 27 
Dubois (d 1 Amiens), 189 
Duncan, 319 
Dyschromatopsia, 197 
Dysmenorrhea, 119, 153, 231 
Dyspepsia. 33 
Dyspnoea, 39, 85, 165 
Dysuria, 37, 109 

Ears, 4 

Ebstein on unilateral hyperhidrosis, 
124 

Ecchymoses, 151 

Echeverria, 33 

Ecstasy, 216, 236 

Eczema facialis, 150 

Edebohls on menstrual dermato- 
neurosis, 153 

Electrotherapy, 253, 317 

Elimination of diseased products, 
277 

Ellinger, 320 

Emmet, 326 

Endocervicitis, 230 

Endometritis, 233 

a causative factor, 9, 71, 89, 90, 

154 
hepatic obstruction in, 91 

Engelmann, 5, 93, 186 

Enteralgia, 99, 163 

Enuresis, 27, 110 

Epigastric swelling, 90 

Ephidrosis, 121 

Epilepsy, 12 

Errors of refraction and accommo- 
dation, 4 

Eructations, hysterical. 166 

Eruptions at puberty, 150 
at the menopause, 150 
of the face, 155 

Erysipelas, "chronic,"' 49 

Ether, 304 

Excessive perspirations, 49 

Exclusivism in medical practice, 7 



360 



INDEX. 



Excretion of urea, 254 
Exophthalmic goitre, 680 
Expectant attention, 27 
External hydrotherapy, 253 
Eye strain, 3, 4 

Faintness, 89 

False croup, 306 

Fatalistic standpoint, 253 

Faucheron, 244 

Fear, a factor in disease, 251 

Ferber, 256 

Fermentation products, 260 

Fever, hysterical, 179 

Flatulence, 98, 153, 317 

Flushing, unilateral, 64, 65 

Food accessories, 295 

Fowler's solution, 156, 299 

Fraenkel on dyspnoea and hyperhi- 

drosis, 122 
Fried meats, 153, 273 
Functional disease, 6, 182 
paralysis, 30 



Gaube on hysterogenic zones, 199 
General nledicine, 9 

practitioner, 2, 3, 10, 
Genital and digestive organs inti- 
mately connected, 11 

reflex neuroses, 112 

weakness, anaemia present, 8 
Genito-urinary organs, 4 

disturbance, 112 
Gilles de la Tourette, 163 
Glandular reflex neuroses, 118 
Globus hystericus, 6, 11, 27, 90, 119 
Glossitis, superficial forms, 141 
Glycogenic functions of the liver, 121 
Griffin Brothers, 36 
Gross on anachlorhydria, 91, 92 

on cerebro-abdominal neurosis, 
99 
Gynecologist, 6, 151 

surgical, 3 
Gynecologist's range of vision, 9 

knowledge of digestive disor- 
ders, 11 



Galvanism, 85 
Gamgee, 201 

Ganglionic nerves, irritation trans- 
mitted through, 9 

nerves observations on, 36 

system, 48 
Gaseous eructations, 107 
Gasserian ganglion, 142 
Gastralgia at menstruation, 93, 212 

in cases of retroversion, 8 
Gastric catarrh, 5 

disturbance, frontal headache 
in, 91 

disturbance, uterine symptoms 
of, 91 

irritation, 15 

neuroses of pregnancy, 93 

neuroses, persistence of, 93 
Gastric reflex indigestion, 89 
Gastric reflex neuroses, 89 

common, 89 
Gastrodynia, hysterical, 308 
Gastro-enteric catarrh, 93 
Gastro-hystero-neuroses, 90 
Gastro-intestinal catarrh, results of, 
49 

tract, irritations in, 11 



Haemorrhoids, 4, 108 

Hallucinations, 113, 139 

Hamilton, 185 

Hanks, 325 

Hart, Ernest, 201 

Hart and Barbour, 185 

Hartmahn, unilateral hyperhidro- 

sis, 125 
Haut mal, 220 
Haziness of vision, 130 
Headache, 247 

bilious, 16 

congestive reflex, 6, 10, 12, 247 

hypersemic, 247 

migrainous, 95, 315 

occipital, 95 
Heaviness and soreness of upper ex- 
tremities, 40 
Heitzmann, 262 
Hemiplegia, hysterical, 166 
Hemidrosis, 122 

Hemeralopia (night blindness), 128 
Hemianesthesia, 11, 165 
Hemicrania, 13, 243 

ansemic type, 51 

a vasomotor neurosis, 51 

from ovarian irritation, 51 



INDEX. 



361 



Hemicrania, hyperaemic type, 51 
Hemorrhagic spots, 151 

perspirations, 151 
Hepatic stimulation, 99 

obstruction, 109 
Hereditary nervous weakness, 59 

diet and regimen in, 59 

educational treatment in, 59 

massage in, 59 

predisposition, 253 
Herpes, 150 
Hiccough a respiratory neurosis, 85 

causes of, 86 

hysterical, 166 

treatment, 86 
Highest art of the physician, 253 
Hilton on hysterical pain, 145 
Hodge, 7 

Hoffman's anodyne, 304 
Hot applications to spine, 40 

baths, 261 

flushes, 73 
Hutchinson on unilateral myosis, 

131 
Hydraemia, treatment of, 40 
Hydrocephalus, 130 
Hydrotherapy, 40, 115. 167 
Hygiene, 253 
Hygienic exercises, 85 
Hyperesthesia, 165, 197 

of all the special senses, 139 
Hyperhidrosis, unilateral, 121 
Hypersecretion of salivary glands. 

119 
Hypersensitiveness of nervous sys- 
tem, 5 
Hypnotism, 27, 187 
Hypochondriacal patients, 41 
Hypogastric neuroses, 112 

plexus, 22 
Hysteria, 157 

age, 159 

anaemia in, 158 

anaesthesia, 161 

characteristics, 160 

climate, 159 

contracture, 161 

diagnosis, 161 

due to constitutional weakness, 
158 

hemianaesthesia, 161 



Hysteria, hemicrania, 162 

hereditary taint, 158 

hyperaesthesia, 162 

impaired digestion 158 

insanity, 159 

major, 190 

morbid fancies, 159 

neuralgias, 162 

occurs in epidemics, 153 

sedentary occupations, 159 

sensory disturbance, 161 

treatment, 181 
Hysteric suffocation, 94 
Hysterical aura, 197, 198 

contractures, 173 

convulsions, 167, 169, 181 

fever. 179 

gastrodynia, 308 

joint, 144 

psychoses, 179 

salivation, 179 

somnambulism, 180 

somnolence, 181 

stigmata, 167 

strabismus. 123 

trance, 181 

trismus, 90 

vasomotor manifestation, 62 

yawnings, 194 
Hystero- catalepsy, 216 
Hystero-epilepsy, 183 

according to Charcot and Ri- 
cher, 133 

attacks of catalepsy, 190 

attacks of lethargy, 190 

attacks of somnambulism, 190 

contortions, 203 

demoniacal attack, 203 

disorders of circulation, 194 

disorders of digestive function, 
193 

disorders of motility, 196 

disorders of respiration, 194 

disorders of secretion. 194 

disorders of sensation. 196 

dysmenorrhea a common 
cause of, 217 

emotional attitudes, 203 

exalted emotions. 191 

hallucinations. 191 

hemianaesthesia, 196 



362 



IKDEX. 



Hystero-epilipsy, opisthotonic posi- 
tion, 218 

period of delirium, 213 

prodromic period, 190 

sorrowful hallucinations, 207, 
208 

tables of, 205, 206 

with combined crises, 189 

with distinct crises, 189 
Hystero-epileptic attack, 184 
Hysterogenetic zones, 199 
Hystero-neuroses, 8, 112 

ophthalmic, 216 

Iconographie de la Salpetriere, 163 
Idiopathic oedema, 79 
Idiosyncrasy, 275 
Impaction of colon, 98 
Incipient renal disease, 129 
Indigestion, 4, 6, 50 
Induration of cervix, 90 
Inflammatory exudates, 260 
Insanity, 159, 314 

hysterical, 28 
Insomnia, 39, 270, 286 
Insufficient or improper diet, 139 
Internal hydrotherapy, 253, 260 

or tissue asepsis, 253, 260 

sterilization, 253, 260 
Intestinal catarrh, 4 

glands, hypersecretion of, 98 
Introspection, constant, 270 
Irritability, excessive, 27 
Irritations, peripheral, 3 

of cord, 22 

of ovary, 22 
Iron, 302 
Isolation, 237 

Joint ankylosis, 144 

neuroses, 27 

pains, 27, 144 

stiffness, 144 

weakness, 144, 147 
Joints and ganglia of sympathetic, 
148 

and ovarian irritations, 147 

and spinal nerves, 148 

and uterus, 147 

Kaempf on cervical sympathetic, 131 



Keating, 62 

Keen on cervical sympathetic, 131 

Kidneys, 4 

granular, 107 

irritability, 106 

neuralgic pains, 106 

secretion, 106 

under control of sympathetic, 
121 
Klebs, 263 
Koch, 258 
Kretol, emulsion of, 156 

Lacerated cervix, 3, 234 

cervix, reflex neuroses depend- 
ent on, 9, 144 
Lactation and affections of the eye, 

133 
Lameness, a psychosis, 144 
Laryngeal reflex neuroses, 81 
Laryngismus, hysterical, 27 

stridulus, 82 
Laryngitis of reflex origin, 81 
Laryngologist, 12 
La Tourette. 163 
Laughter, hysterical, 166 
Lee, 185 
Lehman, 255 
Leichtenstern, 253, 254 
Leonard on female voice in sexual 

disease, 83 
Lesions in lung a cause of reflex 

pain, 17 
Leszynsky, 309 
Lethargy, 113, 221 

complicated by contractions or 
by cataleptoid state, 221 

intense, 27 

simple, 221 

with apparent death, 221 
Lichen, 150 
Liebreich, 201 
Lingual neuralgia, 140 

local applications in, 140 
Lithsemic conditions, 16 
Liver, affections of, 38 
Lobelia in nervous asthma. 316 
Louyer Villermay, 189 
Lumbar ganglia, 22 

plexus, 17 
Lumbo-abdominal neuralgias, 22 



INDEX. 



363 



Malapert, 174. 
Malassimilation, 13, 235 
Mallendorf, 241 
Mammary glands, 118 

changes in, 118 

pain, 118, 153 

swelling, 118 
Mania, 27 

chronic, 12 
Marsh, 116 

Massage, 169, 182, 261, 288 
Mastodynia, remedial measures in, 

118 
Mechanical purification, 260 
Medicinal treatment, 297 
Melancholia, 27, 94, 229, 300, 305 
Memory, loss of, 27 
Menopause, 43, 45 

vasomotor neuroses of, 74 
Menorrhagia, 232 

Menstrual congestion, morbid appe- 
tite at, 91 

hystero-neuroses, 8 
Menstruation, 83 

gastric changes during, 91 

oedema preceding, 77 

sudden suppression of, 90 

vicarious, 77 
Mental depression, 27, 139, 211 

disturbances, vasomotor change 
in, 50 

influences in cardiac neuroses, 
45 
Metabolism, 253 
Micro-organisms, 259 
Migraine, 12, 29, 234, 243, 328 

congestive type, 305 

production of, 14 

treatment of, 245 
Mills, 184, 186 

Mitchell, 62, 130, 167, 168, 181, 184, 
283 

on cervical sympathetic, 130 

on hysteria, 167 

on hysterical contractures, 167 

on treatment, 283 
Morbid appetites, cravings, 91, 96 

fears, 27 

flushing at menopause, 48, 306 

flushing a vasomotor paralysis, 
50 



Morbid flushing, chronic gastroin- 
testinal catarrh in, 49 

flushing, inherited, 55 

flushing or blushing, 48 

flushing, salivation in, 49 

flushing, treatment, 61 

growths, 4 
Morehouse, 131 
Molimen menstruate, 155 
Motor disturbances, migratory, 40 
Mouches volantes, 128, 130 
Midler, 319 
Murray, on anidrosis, 127 

on bromidrosis, 126 

on hyperhidrosis, 126 
Murray's treatment, 126 
Muscular exercises, 264 
Mydriasis, 128, 130 

ephemeral, 136 

functional, 135 
Myosis, 121, 128, 130, 132 

Narcolepsy, 113 
Narcotics, 306 
Nasse, 254 
Xausea, 95 

and vomiting, 39 
Nebel, 241 
Nervous disorders, 3 

exhaustion, 27 

prostration, 41, 106 

system, disturbance of, 2 
Neuralgia, inflammatory local, 7 
Neuralgias, 306 

cardiac, 14 

digital, 16 

during pregnancy, 140 

intercostal, 14 

in the heel and wrist, 16 

lingual, 140 

migratory, 40 

transferred or reflex, 14 
Neurasthenia, 27 

anachlorhydria in, 91 
Neurasthenic conditions, 16 

patients, 45 
Neurologist, 6 
Neuroses, classification, 13 

combined, 13 

common, 13 

definition, 2 



364 



INDEX. 



Neuroses, general or local, 2 

of menstrual period, 90 

reflex, 1, 2 
Niemeyer, 256 

Night blindness (hemeralopia), 128 
Non-bacteriological affections, 252 
New growths. 4 
Nyctalopia (day blindness), 128 

Obesity, 289 

Ocular tenotomy, enthusiast in, 2 

Oculist, 6 

Oculo-pupillary disorders, 130 

O'Dwyer, 327 

(Edema, acute idiopathic, 79 

angeio-neurotic, 77 

circumscribed, 79 

indefinite duration, 78 

lympathics in, 77 

non-inflammatory, 79 

veins in, 77 
(Edema, hysterical, 80 

varieties, 80 
Oophorectomy for hystero-epilepsy, 

186 
Oophoritis, 230 
Ophthalmic reflex neuroses, 128 

symptoms, 128 
Opiates, 306 

Opium and valerian, 306 
Organic or structural disease, 6 
Orgasms, 116 

treatment, 116 
Out-of-door exercise, 60 
Ovarian hyperesthesia, 210 

irritation, 114 

neuralgia, 306 

pain, 119 
Ovary, cystic, 3 
Overexertion, 253 
Oxalate-of-lime crystals in urine, 106 

Paget, 146 

Pain at the hip joint, 144 

frontal or temporal, 14 

gall bladder, 16 

in abscess of spleen, 16 

in the knee, 144 

in the wrist or ankle, 144 

kidney, 15 

occipital, 15 



Pain, scapular or shoulder, 15 

transferred, 15, 17 
Pallor of face, extreme, 50 
Palmer, 320, 

Palpitation of the heart, 39 
Palsy, facial, 31 
Pancreatic digestion, 297 
Paralysis, ansemic, 31, 32 

complete, 31 

crutch, 31 

functional, 30 

hysterical, 30 

organic, 32 

partial, 31 

vesical, 31 
Paraplegia, 11, 31, 32 
Parasites in milk, 279 
Parotid glands and reproductive 

organs, 119 
Parotiditis and oophoritis, 120 
Passions of the mind, 252 
Peas lee, 323 
Pelvic cellulitis, 6 

irritations, 17 
Period of delirum, 213 
Periodic swelling, 79 
Peripheral irritation, 3 
Perspirations, excessive, of hands 
and feet, 120 

localized, 124 

malodorous, 120 
Phagocytosis. 259 
Pharyngeal inflammation, 12 

reflex neuroses, 81 
Pharyngitis, chronic, from imper- 
fect digestion, 82 

of reflex origin, 81 
Photophobia, 130 
Phthisis, 259 

intercostal neuralgia in, 17 
Physical exercise, 265 
Physicians, practical, 1 

scientific, 1 
Pigmentation, 153 
Pneumogastric nerve, 22 
Podalgias, 22 
Polyuria, 107, 108 
Portal circulation, 90 
Post-nasal catarrh, 50 
Practitioner, general, 2 
Pregnancy and visual apparatus, 133 



INDEX. 



305 



Preparation of meat, 274 
Prophylaxis, 252, 253 

modern, 252 
Proteids, 273 
Prurigo, 150 
Pruritus, 150 

ani, 3 
Pseudo-angina pectoris, 42, 45, 107 

treatment of, 43 
Psychological treatment, 129 
Psychoses or cerebral neuroses, 27, 

28, 300 
Ptosis a reflex from gastric or hepat- 
ic disease, 129 
Puerperal amaurosis, 129 

mania, 28 

melancholia, 28 
Puerperium and eye affections, 133 
Pulmonary disease, 5 
Pulse, 75 

Quinine sulphate, 299 

Reconstructive remedies, 297 

Rectum, 4 

Reflex asthma, 306 

conditions, 6 

coughs, 306 

disturbance, 4 
Reflex dermatoses dependent on 
menstrual disturbance, 151 

hystero-neuroses, 5 

pains are transferred pains, 14 

pains from viscera, 22 

vasomotor changes, 14 
Reflex neuroses, 1 

congestion in, 11 

differential diagnosis, 11 

symptoms in, 10 
Renal reflex neuroses, 106 

hypersecretion, 106 

irritability, 106 

nervous prostration in, 106 

secretions, 106 
Rendu on unilateral mydriasis, 132 
Retinal anaesthesia, 128 

hyperesthesia, 128 
Retroflexion, 233 
Rhinitis, chronic, 82 
Rhinologist, 12 
Richer, 164, 170, 173, 176, 190, 196 



Rockwell on unilateral hyperhidro- 

sis, 124 
Rosenthal on unilateral mydriasis, 

131, 132 
Routine practice, 252 

Salivation, 308 
Salpetriere, 176 
Sandras, 189' 
Sayre, 171 
Schmidt, 255 
Schroeder, 318 
Sciatica, 22, 132 
Scientific physicians, 1 

problems, 1 
Scrofulous diathesis, 107 
Seasickness, treatment of, 305 
Seborrhoea, 152 
Seeligmuller on atrophy of cheek, 

131 
Sensation, reflex, disturbances of, 

in lower extremities, 8 
Seguin on unilateral hyperhidrosis> 

122 
Sexual apparatus, 118 

orgasms, recurrent, 114 
Shouting, hysterical, 166 
Simulated disease, 36 
Simulation of disease, 2 
Simpson, 305, 319 
Sims, 320, 323 
Sneezing, reflex, 86 
Solar plexus, 35 
Sollier, 174 
Somnambulism, 270 

hysterical, 180, 211, 215 
Souques, 179 
Spasm, hysterical, 165, 168 

muscular, 15 

of bladder, 16 

of larynx, 165 

of oesophagus, 165 

of pharynx, 165, 194 

of sterno-cleido-mastoid, 165 

of trapezius, 165 
Special feeding, 289 

treatment, 251 
Specialist, 2, 3 
Spinal irritation, 34, 38, 233 

anoemic form, 41 

hypenemic form, 39 



366 



INDEX. 



Spinal irritation, treatment, 41 

inflammation, 38 

pains, 34 

reflex neuroses, 34 

system, 5 

tenderness, 37, 157 
Splanchnic nerve, 35 
Spurious peritonitis, 187, 197 
Squint, hysterical, 165 
Stammering, 140 
Stenosis case, 327 
Strabismus, hysterical, 128, 165 
Strengthening treatment, 251 
Suffocation, hysterical, 27, 94 
Surgeon, 6 

Sydenham's chorea, 163 
Sympathetic ganglia, 20, 21 

pains, 34 

system, 5 
Sympathy for minor ailments, 2 
Symptomatic chloasmata, 150, 151 

treatment, 252 
Symptoms, abdominal, 2 

uterine, 2 
Systematic constitutional treat- 
ment, 253 

Tachycardia, 176 

Therapeutics, 251 

Thomson, 328 

Thread-worms, 4 

Thyroid, swollen, 6, 119 

Tilt, 7 

Tissot, 189 

Todd on hysterical hemiplegia, 166 

Trance, 27, 113, 221, et seq. 

table, 223 
Trismus, hysterical, 90 
Tropho-neuroses, 80 
Tubercle bacillus, 259 
Tuberculosis, 258 
Tumefaction, 153 
Turner, 201 
Tympanites, 90, 194 

Unhygienic living, 50 
Unilateral sweating, 123 
Urination, difficult, 108 

effect of fear or fright on, 106 

frequent, 108 

incontinence, 108 



Urination, pain after, 108 
painful, 108 
retention, 108 
Urine, hyperacid, 108 
nervous, 194 
pale, 107 
Urticaria, 80, 150 
giant, 79 
tuberosa, 79 
Uterine disease, 152 

a cause of insanity, 7 
gastric neurosis most fre- 
quent in, 92 
disorders at menopause, 8 
examination of unmarried, 10 
involution, 29 
neuralgia, 96, 308 
neuroses, 92 
pain, 119 
Uterus and eye, 132 

growth and activity of, during 
pregnancy a cause of reflex 
neuroses, 88 

Vascular reflex neuroses, 47 
burnings of the palms, 47 
burnings of the side of the chest, 

48 
burnings of the soles of the feet, 

47 
burnings of the top of the head, 

47 
coldness of extremities, 48 
erythematous eruptions, 48 
external or internal, 47 
flushes, 47 
flushing of malar prominences, 

47 
general or local, 47 
general or nervous chills, 47 
hemorrhages, 48 
of puerperal circulation, 47 
sweats, 48 
Vasomotor disorder, functional, 64, 

101 
ganglia, €>S 
nerves, 65, 66, 67, 68 
neuroses of pelvic origin, 65 
spasmodic varieties, 70, 72, 
73 
paresis of lower extremities, 62 



INDEX. 



367 



Vegetable diet, 278 

. foods, 294 
Yertigo, 39 
Vesical reflex neuroses, 108 

causes of, 108 

varieties, 108 
Virchow, 201 
Vitality, 253 

lowered, 5 

in patients, 44 
Voice, changes in, at the time of 

menstruation, 83 
Voit, 256 

Voluntary blushing, 57 
Vomiting, reflex, 305, 308 

nausea and, 39 

violent, 8, 95 

Wakefulness, 27 



Wallet, 178 

Water, internal use of, 253 

Watson, 241 

Weeping, hysterical, 94, 166 

Weyrich, 256 

Wilson, on hyperhidrosis, 125 

Wines, generous, 298. 300 

Woman, functional derangements, 1 

physical discomforts, 1 
Women, neuroses of, 3 
Worry and anxiety, 269 

Yawning, a trivial neurosis, 86 
causes of, 86 
hysterical, 166 

Zander, 251, 264, 268 
Ziemssen, 253 




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